---
kind: "section"
citation: "42 U.S.C. § 1396t"
title: "42"
title_heading: "The Public Health and Welfare"
number: "1396t"
heading: "Home and community care for functionally disabled elderly individuals"
release: "119-102"
date: "2026-07-12"
url: "https://uscodex.org/usc/42/1396t"
units:
  - "Chapter 7 — Social Security"
  - "Subchapter XIX — Grants to States for Medical Assistance Programs"
---

# §1396t. Home and community care for functionally disabled elderly individuals

- (a) **“Home and community care” defined—** In this subchapter, the term “home and community care” means one or more of the following services furnished to an individual who has been determined, after an assessment under [subsection (c)](#c), to be a functionally disabled elderly individual, furnished in accordance with an individual community care plan (established and periodically reviewed and revised by a qualified community care case manager under [subsection (d)](#d)):
  - (1) Homemaker/home health aide services.
  - (2) Chore services.
  - (3) Personal care services.
  - (4) Nursing care services provided by, or under the supervision of, a registered nurse.
  - (5) Respite care.
  - (6) Training for family members in managing the individual.
  - (7) [Adult](/usc/42/619.md?p=1) day care.
  - (8) In the case of an individual with chronic mental illness, day [treatment](/usc/42/11851.md?p=11) or other partial [hospitalization](/usc/42/1301.md?p=a-7), psychosocial rehabilitation services, and clinic services (whether or not furnished in a [facility](/usc/42/1320a–3.md?p=c-5-B)).
  - (9) Such other home and community-based services (other than room and board) as the [Secretary](/usc/42/1301.md?p=a-6) may approve.
- (b) **“Functionally disabled elderly individual” defined—**
  - (1) **In general—** In this subchapter, the term “functionally disabled elderly individual” means an individual who—
    - (A) is 65 years of age or older,
    - (B) is determined to be a functionally disabled individual under [subsection (c)](#c), and
    - (C) subject to [section 1396a(f) of this title](/usc/42/1396a.md?p=f) (as applied consistent with [section 1396a(r)(2) of this title](/usc/42/1396a.md?p=r-2)), is receiving supplemental security income benefits under subchapter XVI (or under a [State](/usc/42/619.md?p=5) plan approved under subchapter XVI) or, at the option of the [State](/usc/42/619.md?p=5), is described in [section 1396a(a)(10)(C) of this title](/usc/42/1396a.md?p=a-10-C).
  - (2) **Treatment of certain individuals previously covered under a waiver—**
    - (A) In the case of a [State](/usc/42/619.md?p=5) which—
      - (i) at the time of its election to provide coverage for home and community care under this section has a waiver approved under section [1396n(c)](/usc/42/1396n.md?p=c) or [1396n(d)](/usc/42/1396n.md?p=d) of this title with respect to individuals 65 years of age or older, and
      - (ii) subsequently discontinues such waiver, individuals who were eligible for benefits under the waiver as of the date of its discontinuance and who would, but for income or resources, be eligible for [medical assistance](/usc/42/1396d.md?p=a) for home and community care under the plan shall, notwithstanding any other provision of this subchapter, be deemed a functionally disabled elderly individual for so long as the individual would have remained eligible for [medical assistance](/usc/42/1396d.md?p=a) under such waiver.
    - (B) In the case of a [State](/usc/42/619.md?p=5) which used a health insuring organization before January 1, 1986, and which, as of December 31, 1990, had in effect a waiver under [section 1315 of this title](/usc/42/1315.md) that provides under the [State](/usc/42/619.md?p=5) plan under this subchapter for personal care services for functionally disabled individuals, the term “functionally disabled elderly individual” may include, at the option of the [State](/usc/42/619.md?p=5), an individual who—
      - (i) is 65 years of age or older or is disabled (as determined under the supplemental security income program under subchapter XVI);
      - (ii) is determined to meet the test of functional disability applied under the waiver as of such date; and
      - (iii) meets the resource requirement and income [standard](/usc/42/1320d.md?p=7) that apply in the [State](/usc/42/619.md?p=5) to individuals described in [section 1396a(a)(10)(A)(ii)(V) of this title](/usc/42/1396a.md?p=a-10-A-ii-V).
  - (3) **Use of projected income—** In applying [section 1396b(f)(1) of this title](/usc/42/1396b.md?p=f-1) in determining the eligibility of an individual (described in [section 1396a(a)(10)(C) of this title](/usc/42/1396a.md?p=a-10-C)) for [medical assistance](/usc/42/1396d.md?p=a) for home and community care, a [State](/usc/42/619.md?p=5) may, at its option, provide for the determination of the individual’s anticipated medical expenses (to be deducted from income) over a period of up to 6 months.
- (c) **Determinations of functional disability—**
  - (1) **In general—** In this section, an individual is “functionally disabled” if the individual—
    - (A) is unable to perform without substantial assistance from another individual at least 2 of the following 3 activities of daily living: toileting, transferring, and eating; or
    - (B) has a primary or secondary diagnosis of Alzheimer’s disease and is (i) unable to perform without substantial human assistance ([including](/usc/42/1301.md?p=b) verbal reminding or physical cueing) or supervision at least 2 of the following 5 activities of daily living: bathing, dressing, toileting, transferring, and eating; or (ii) cognitively impaired so as to require substantial supervision from another individual because he or she engages in inappropriate behaviors that pose serious health or safety hazards to himself or herself or others.
  - (2) **Assessments of functional disability—**
    - (A) **Requests for assessments—** If a [State](/usc/42/619.md?p=5) has elected to provide home and community care under this section, upon the request of an individual who is 65 years of age or older and who meets the requirements of [subsection (b)(1)(C)](#b-1-C) (or another [person](/usc/42/1301.md?p=a-3) on such individual’s behalf), the [State](/usc/42/619.md?p=5) shall provide for a comprehensive functional assessment under this subparagraph which—
      - (i) is used to determine whether or not the individual is functionally disabled,
      - (ii) is based on a uniform minimum data set specified by the [Secretary](/usc/42/1301.md?p=a-6) under [subparagraph (C)(i)](#c-2-C-i), and
      - (iii) uses an instrument which has been specified by the [State](/usc/42/619.md?p=5) under [subparagraph (B)](#c-2-B).

      No fee may be charged for such an assessment.

    - (B) **Specification of assessment instrument—** The [State](/usc/42/619.md?p=5) shall specify the instrument to be used in the [State](/usc/42/619.md?p=5) in complying with the requirement of [subparagraph (A)(iii)](#c-2-A-iii) which instrument shall be—
      - (i) one of the instruments designated under [subparagraph (C)(ii)](#c-2-C-ii); or
      - (ii) an instrument which the [Secretary](/usc/42/1301.md?p=a-6) has approved as being consistent with the minimum data set of core elements, common definitions, and utilization guidelines specified by the [Secretary](/usc/42/1301.md?p=a-6) in [subparagraph (C)(i)](#c-2-C-i).
    - (C) **Specification of assessment data set and instruments—** The [Secretary](/usc/42/1301.md?p=a-6) shall—
      - (i) not later than July 1, 1991—
        - (I) specify a minimum data set of core elements and common definitions for use in conducting the assessments required under [subparagraph (A)](#c-2-A); and
        - (II) establish guidelines for use of the data set; and
      - (ii) by not later than July 1, 1991, designate one or more instruments which are consistent with the specification made under [subparagraph (A)](#c-2-A) and which a [State](/usc/42/619.md?p=5) may specify under [subparagraph (B)](#c-2-B) for use in complying with the requirements of [subparagraph (A)](#c-2-A).
    - (D) **Periodic review—** Each individual who qualifies as a functionally disabled elderly individual shall have the individual’s assessment periodically reviewed and revised not less often than once every 12 months.
    - (E) **Conduct of assessment by interdisciplinary teams—** An assessment under [subparagraph (A)](#c-2-A) and a review under [subparagraph (D)](#c-2-D) must be conducted by an interdisciplinary team designated by the [State](/usc/42/619.md?p=5). The [Secretary](/usc/42/1301.md?p=a-6) shall permit a [State](/usc/42/619.md?p=5) to provide for assessments and reviews through teams under contracts—
      - (i) with public organizations; or
      - (ii) with nonpublic organizations which do not provide home and community care or [nursing facility services](/usc/42/1396d.md?p=f) and do not have a direct or indirect ownership or control interest in, or direct or indirect affiliation or relationship with, an entity that provides, community care or [nursing facility services](/usc/42/1396d.md?p=f).
    - (F) **Contents of assessment—** The interdisciplinary team must—
      - (i) identify in each such assessment or review each individual’s functional disabilities and need for home and community care, [including](/usc/42/1301.md?p=b) information about the individual’s health status, home and community environment, and informal support system; and
      - (ii) based on such assessment or review, determine whether the individual is (or continues to be) functionally disabled.

      The results of such an assessment or review shall be used in establishing, reviewing, and revising the individual’s ICCP under [subsection (d)(1)](#d-1).

    - (G) **Appeal procedures—** Each [State](/usc/42/619.md?p=5) which elects to provide home and community care under this section must have in effect an appeals process for individuals adversely affected by determinations under [subparagraph (F)](#c-2-F).
- (d) **Individual community care plan (ICCP)—**
  - (1) **“Individual community care plan” defined—** In this section, the terms “individual community care plan” and “ICCP” mean, with respect to a functionally disabled elderly individual, a written plan which—
    - (A) is established, and is periodically reviewed and revised, by a qualified case manager after a face-to-face interview with the individual or primary caregiver and based upon the most recent comprehensive functional assessment of such individual conducted under [subsection (c)(2)](#c-2);
    - (B) specifies, within any amount, duration, and scope limitations imposed on home and community care provided under the [State](/usc/42/619.md?p=5) plan, the home and community care to be provided to such individual under the plan, and indicates the individual’s preferences for the types and providers of services; and
    - (C) may specify other services required by such individual.

    An ICCP may also designate the specific providers (qualified to provide home and community care under the [State](/usc/42/619.md?p=5) plan) which will provide the home and community care described in [subparagraph (B)](#d-1-B). Nothing in this section shall be construed as authorizing an ICCP or the [State](/usc/42/619.md?p=5) to restrict the specific [persons](/usc/42/1301.md?p=a-3) or individuals (who are competent to provide home and community care under the [State](/usc/42/619.md?p=5) plan) who will provide the home and community care described in [subparagraph (B)](#d-1-B).

  - (2) **“Qualified community care case manager” defined—** In this section, the term “qualified community care case manager” means a [nonprofit](/usc/42/300s–3.md?p=3) or [public agency](/usc/42/11851.md?p=8) or organization which—
    - (A) has experience or has been trained in establishing, and in periodically reviewing and revising, individual community care plans and in the provision of [case management services](/usc/42/701.md?p=b-4) to the elderly;
    - (B) is responsible for (i) assuring that home and community care covered under the [State](/usc/42/619.md?p=5) plan and specified in the ICCP is being provided, (ii) visiting each individual’s home or community setting where care is being provided not less often than once every 90 days, and (iii) informing the elderly individual or primary caregiver on how to contact the case manager if service providers fail to properly provide services or other similar problems occur;
    - (C) in the case of a nonpublic agency, does not provide home and community care or [nursing facility services](/usc/42/1396d.md?p=f) and does not have a direct or indirect ownership or control interest in, or direct or indirect affiliation or relationship with, an entity that provides, home and community care or [nursing facility services](/usc/42/1396d.md?p=f);
    - (D) has procedures for assuring the quality of [case management services](/usc/42/701.md?p=b-4) that [includes](/usc/42/1301.md?p=b) a peer review process;
    - (E) completes the ICCP in a timely manner and reviews and discusses new and revised ICCPs with elderly individuals or primary caregivers; and
    - (F) meets such other [standards](/usc/42/1320d.md?p=7), established by the [Secretary](/usc/42/1301.md?p=a-6), as to assure that—
      - (i) such a manager is competent to perform case management functions;
      - (ii) individuals whose home and community care they manage are not at risk of financial [exploitation](/usc/42/1397j.md?p=8) due to such a manager; and
      - (iii) meets such other [standards](/usc/42/1320d.md?p=7) as the [State](/usc/42/619.md?p=5) may establish.

    The [Secretary](/usc/42/1301.md?p=a-6) may waive the requirement of [subparagraph (C)](#d-2-C) in the case of a [nonprofit](/usc/42/300s–3.md?p=3) [agency](/usc/42/1397n–12.md?p=1) located in a rural area.

  - (3) **Appeals process—** Each [State](/usc/42/619.md?p=5) which elects to provide home and community care under this section must have in effect an appeals process for individuals who disagree with the ICCP established.
- (e) **Ceiling on payment amounts and maintenance of effort—**
  - (1) **Ceiling on payment amounts—** Payments may not be made under [section 1396b(a) of this title](/usc/42/1396b.md?p=a) to a [State](/usc/42/619.md?p=5) for home and community care provided under this section in a quarter to the extent that the [medical assistance](/usc/42/1396d.md?p=a) for such care in the quarter exceeds 50 percent of the product of—
    - (A) the average number of individuals in the quarter receiving such care under this section;
    - (B) the average per diem rate of payment which the [Secretary](/usc/42/1301.md?p=a-6) has determined (before the beginning of the quarter) will be payable under subchapter XVIII (without regard to coinsurance) for extended care services to be provided in the [State](/usc/42/619.md?p=5) during such quarter; and
    - (C) the number of days in such quarter.
  - (2) **Maintenance of effort—**
    - (A) **Annual reports—** As a condition for the receipt of payment under [section 1396b(a) of this title](/usc/42/1396b.md?p=a) with respect to [medical assistance](/usc/42/1396d.md?p=a) provided by a [State](/usc/42/619.md?p=5) for home and community care (other than a waiver under [section 1396n(c) of this title](/usc/42/1396n.md?p=c) and other than home health care services described in [section 1396d(a)(7) of this title](/usc/42/1396d.md?p=a-7) and personal care services specified under regulations under [section 1396d(a)(23) of this title](/usc/42/1396d.md?p=a-23)), the [State](/usc/42/619.md?p=5) shall report to the [Secretary](/usc/42/1301.md?p=a-6), with respect to each Federal [fiscal year](/usc/42/619.md?p=3) (beginning with [fiscal year](/usc/42/619.md?p=3) 1990) and in a format developed or approved by the [Secretary](/usc/42/1301.md?p=a-6), the amount of funds obligated by the [State](/usc/42/619.md?p=5) with respect to the provision of home and community care to the functionally disabled elderly in that [fiscal year](/usc/42/619.md?p=3).
    - (B) **Reduction in payment if failure to maintain effort—** If the amount reported under [subparagraph (A)](#e-2-A) by a [State](/usc/42/619.md?p=5) with respect to a [fiscal year](/usc/42/619.md?p=3) is less than the amount reported under [subparagraph (A)](#e-2-A) with respect to [fiscal year](/usc/42/619.md?p=3) 1989, the [Secretary](/usc/42/1301.md?p=a-6) shall provide for a reduction in payments to the [State](/usc/42/619.md?p=5) under [section 1396b(a) of this title](/usc/42/1396b.md?p=a) in an amount equal to the difference between the amounts so reported.
- (f) **Minimum requirements for home and community care—**
  - (1) **Requirements—** Home and Community[^1] care provided under this section must meet such requirements for individuals’ rights and quality as are published or developed by the [Secretary](/usc/42/1301.md?p=a-6) under [subsection (k)](#k). Such requirements shall include—
    - (A) the requirement that individuals providing care are competent to provide such care; and
    - (B) the rights specified in [paragraph (2)](#f-2).
  - (2) **Specified rights—** The rights specified in this paragraph are as follows:
    - (A) The right to be fully informed in advance, orally and in writing, of the care to be provided, to be fully informed in advance of any changes in care to be provided, and (except with respect to an individual determined incompetent) to participate in planning care or changes in care.
    - (B) The right to voice grievances with respect to services that are (or fail to be) furnished without discrimination or reprisal for voicing grievances, and to be told how to complain to [State](/usc/42/619.md?p=5) and local authorities.
    - (C) The right to confidentiality of personal and clinical records.
    - (D) The right to privacy and to have one’s property treated with respect.
    - (E) The right to refuse all or part of any care and to be informed of the likely consequences of such refusal.
    - (F) The right to education or training for oneself and for members of one’s family or household on the management of care.
    - (G) The right to be free from physical or mental [abuse](/usc/42/1397j.md?p=1), corporal punishment, and any physical or chemical restraints imposed for purposes of discipline or convenience and not included in an individual’s ICCP.
    - (H) The right to be fully informed orally and in writing of the individual’s rights.
    - (I) Guidelines for such minimum compensation for individuals providing such care as will assure the availability and continuity of competent individuals to provide such care for functionally disabled individuals who have functional disabilities of varying levels of severity.
    - (J) Any other rights established by the [Secretary](/usc/42/1301.md?p=a-6).
- (g) **Minimum requirements for small community care settings—**
  - (1) **“Small community care setting” defined—** In this section, the term “small community care setting” means—
    - (A) a nonresidential setting that serves more than 2 and less than 8 individuals; or
    - (B) a residential setting in which more than 2 and less than 8 unrelated [adults](/usc/42/619.md?p=1) reside and in which personal services (other than merely board) are provided in conjunction with residing in the setting.
  - (2) **Minimum requirements—** A small community care setting in which community care is provided under this section must—
    - (A) meet such requirements as are published or developed by the [Secretary](/usc/42/1301.md?p=a-6) under [subsection (k)](#k);
    - (B) meet the requirements of paragraphs (1)(A), (1)(C), (1)(D), (3), and (6) of [section 1396r(c) of this title](/usc/42/1396r.md?p=c), to the extent applicable to such a setting;
    - (C) inform each individual receiving community care under this section in the setting, orally and in writing at the time the individual first receives community care in the setting, of the individual’s legal rights with respect to such a setting and the care provided in the setting;
    - (D) meet any applicable [State](/usc/42/619.md?p=5) or local requirements regarding certification or licensure;
    - (E) meet any applicable [State](/usc/42/619.md?p=5) and local zoning, building, and housing codes, and [State](/usc/42/619.md?p=5) and local fire and safety regulations; and
    - (F) be designed, constructed, equipped, and maintained in a manner to protect the health and safety of residents.
- (h) **Minimum requirements for large community care settings—**
  - (1) **“Large community care setting” defined—** In this section, the term “large community care setting” means—
    - (A) a nonresidential setting in which more than 8 individuals are served; or
    - (B) a residential setting in which more than 8 unrelated [adults](/usc/42/619.md?p=1) reside and in which personal services are provided in conjunction with residing in the setting in which home and community care under this section is provided.
  - (2) **Minimum requirements—** A large community care setting in which community care is provided under this section must—
    - (A) meet such requirements as are published or developed by the [Secretary](/usc/42/1301.md?p=a-6) under [subsection (k)](#k);
    - (B) meet the requirements of paragraphs (1)(A), (1)(C), (1)(D), (3), and (6) of [section 1396r(c) of this title](/usc/42/1396r.md?p=c), to the extent applicable to such a setting;
    - (C) inform each individual receiving community care under this section in the setting, orally and in writing at the time the individual first receives home and community care in the setting, of the individual’s legal rights with respect to such a setting and the care provided in the setting; and
    - (D) meet the requirements of paragraphs (2) and (3) of [section 1396r(d) of this title](/usc/42/1396r.md?p=d) (relating to [administration](/usc/42/1301.md?p=a-10) and other matters) in the same manner as such requirements apply to [nursing facilities](/usc/42/1396d.md?p=c) under such section; except that, in applying the requirement of [section 1396r(d)(2) of this title](/usc/42/1396r.md?p=d-2) (relating to life safety code), the [Secretary](/usc/42/1301.md?p=a-6) shall provide for the application of such life safety requirements (if any) that are appropriate to the setting.
  - (3) **Disclosure of ownership and control interests and exclusion of repeated violators—** A community care setting—
    - (A) must disclose [persons](/usc/42/1301.md?p=a-3) with an ownership or control interest ([including](/usc/42/1301.md?p=b) such [persons](/usc/42/1301.md?p=a-3) as defined in [section 1320a–3(a)(3) of this title](/usc/42/1320a–3.md?p=a-3)) in the setting; and
    - (B) may not have, as a [person with an ownership or control interest](/usc/42/1320a–3.md?p=a-3) in the setting, any individual or [person](/usc/42/1301.md?p=a-3) who has been excluded from participation in the program under this subchapter or who has had such an ownership or control interest in one or more community care settings which have been found repeatedly to be substandard or to have failed to meet the requirements of [paragraph (2)](#h-2).
- (i) **Survey and certification process—**
  - (1) **Certifications—**
    - (A) **Responsibilities of the State—** Under each [State](/usc/42/619.md?p=5) plan under this subchapter, the [State](/usc/42/619.md?p=5) shall be responsible for certifying the compliance of providers of home and community care and community care settings with the applicable requirements of subsections [(f)](#f), [(g)](#g) and [(h)](#h). The failure of the [Secretary](/usc/42/1301.md?p=a-6) to issue regulations to carry out this subsection shall not relieve a [State](/usc/42/619.md?p=5) of its responsibility under this subsection.
    - (B) **Responsibilities of the Secretary—** The [Secretary](/usc/42/1301.md?p=a-6) shall be responsible for certifying the compliance of [State](/usc/42/619.md?p=5) providers of home and community care, and of [State](/usc/42/619.md?p=5) community care settings in which such care is provided, with the requirements of subsections [(f)](#f), [(g)](#g) and [(h)](#h).
    - (C) **Frequency of certifications—** Certification of providers and settings under this subsection shall occur no less frequently than once every 12 months.
  - (2) **Reviews of providers—**
    - (A) **In general—** The certification under this subsection with respect to a provider of home or community care must be based on a periodic review of the provider’s performance in providing the care required under ICCP’s in accordance with the requirements of [subsection (f)](#f).
    - (B) **Special reviews of compliance—** Where the [Secretary](/usc/42/1301.md?p=a-6) has reason to question the compliance of a provider of home or community care with any of the requirements of [subsection (f)](#f), the [Secretary](/usc/42/1301.md?p=a-6) may conduct a review of the provider and, on the basis of that review, make independent and binding determinations concerning the extent to which the provider meets such requirements.
  - (3) **Surveys of community care settings—**
    - (A) **In general—** The certification under this subsection with respect to community care settings must be based on a survey. Such survey for such a setting must be conducted without prior notice to the setting. Any individual who notifies (or causes to be notified) a community care setting of the time or date on which such a survey is scheduled to be conducted is subject to a civil money penalty of not to exceed $2,000. The provisions of [section 1320a–7a of this title](/usc/42/1320a–7a.md) (other than subsections [(a)](#a) and [(b)](#b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under [section 1320a–7a(a) of this title](/usc/42/1320a–7a.md?p=a). The [Secretary](/usc/42/1301.md?p=a-6) shall review each [State](/usc/42/619.md?p=5)’s procedures for scheduling and conducting such surveys to assure that the [State](/usc/42/619.md?p=5) has taken all reasonable steps to avoid giving notice of such a survey through the scheduling procedures and the conduct of the surveys themselves.
    - (B) **Survey protocol—** Surveys under this paragraph shall be conducted based upon a protocol which the [Secretary](/usc/42/1301.md?p=a-6) has provided for under [subsection (k)](#k).
    - (C) **Prohibition of conflict of interest in survey team membership—** A [State](/usc/42/619.md?p=5) and the [Secretary](/usc/42/1301.md?p=a-6) may not use as a member of a survey team under this paragraph an individual who is serving (or has served within the previous 2 years) as a member of the staff of, or as a consultant to, the community care setting being surveyed (or the [person](/usc/42/1301.md?p=a-3) responsible for such setting) respecting compliance with the requirements of subsection [(g)](#g) or [(h)](#h) or who has a personal or familial financial interest in the setting being surveyed.
    - (D) **Validation surveys of community care settings—** The [Secretary](/usc/42/1301.md?p=a-6) shall conduct onsite surveys of a representative sample of community care settings in each [State](/usc/42/619.md?p=5), within 2 months of the date of surveys conducted under [subparagraph (A)](#i-3-A) by the [State](/usc/42/619.md?p=5), in a sufficient number to allow inferences about the adequacies of each [State](/usc/42/619.md?p=5)’s surveys conducted under [subparagraph (A)](#i-3-A). In conducting such surveys, the [Secretary](/usc/42/1301.md?p=a-6) shall use the same survey protocols as the [State](/usc/42/619.md?p=5) is required to use under [subparagraph (B)](#i-3-B). If the [State](/usc/42/619.md?p=5) has determined that an individual setting meets the requirements of [subsection (g)](#g), but the [Secretary](/usc/42/1301.md?p=a-6) determines that the setting does not meet such requirements, the [Secretary](/usc/42/1301.md?p=a-6)’s determination as to the setting’s noncompliance with such requirements is binding and supersedes that of the [State](/usc/42/619.md?p=5) survey.
    - (E) **Special surveys of compliance—** Where the [Secretary](/usc/42/1301.md?p=a-6) has reason to question the compliance of a community care setting with any of the requirements of subsection [(g)](#g) or [(h)](#h), the [Secretary](/usc/42/1301.md?p=a-6) may conduct a survey of the setting and, on the basis of that survey, make independent and binding determinations concerning the extent to which the setting meets such requirements.
  - (4) **Investigation of complaints and monitoring of providers and settings—** Each [State](/usc/42/619.md?p=5) and the [Secretary](/usc/42/1301.md?p=a-6) shall maintain procedures and adequate staff to investigate complaints of [violations](/usc/42/2000e–16a.md?p=c) of applicable requirements imposed on providers of community care or on community care settings under subsections [(f)](#f), [(g)](#g) and [(h)](#h).
  - (5) **Investigation of allegations of individual neglect and abuse and misappropriation of individual property—** The [State](/usc/42/619.md?p=5) shall provide, through the [agency](/usc/42/1397n–12.md?p=1) responsible for surveys and certification of providers of home or community care and community care settings under this subsection, for a process for the receipt, review, and investigation of allegations of individual [neglect](/usc/42/1397j.md?p=16) and [abuse](/usc/42/1397j.md?p=1) ([including](/usc/42/1301.md?p=b) injuries of unknown source) by individuals providing such care or in such setting and of misappropriation of individual property by such individuals. The [State](/usc/42/619.md?p=5) shall, after notice to the individual involved and a reasonable opportunity for hearing for the individual to rebut allegations, make a finding as to the accuracy of the allegations. If the [State](/usc/42/619.md?p=5) finds that an individual has neglected or abused an individual receiving community care or misappropriated such individual’s property, the [State](/usc/42/619.md?p=5) shall notify the individual against whom the finding is made. A [State](/usc/42/619.md?p=5) shall not make a finding that a [person](/usc/42/1301.md?p=a-3) has neglected an individual receiving community care if the [person](/usc/42/1301.md?p=a-3) demonstrates that such [neglect](/usc/42/1397j.md?p=16) was caused by factors beyond the control of the [person](/usc/42/1301.md?p=a-3). The [State](/usc/42/619.md?p=5) shall provide for public disclosure of findings under this paragraph upon request and for inclusion, in any such disclosure of such findings, of any brief statement (or of a clear and accurate summary thereof) of the individual disputing such findings.
  - (6) **Disclosure of results of inspections and activities—**
    - (A) **Public information—** Each [State](/usc/42/619.md?p=5), and the [Secretary](/usc/42/1301.md?p=a-6), shall make available to the public—
      - (i) information respecting all surveys, reviews, and certifications made under this subsection respecting providers of home or community care and community care settings, [including](/usc/42/1301.md?p=b) statements of deficiencies,
      - (ii) copies of cost reports (if any) of such providers and settings filed under this subchapter,
      - (iii) copies of statements of ownership under [section 1320a–3 of this title](/usc/42/1320a–3.md), and
      - (iv) information disclosed under [section 1320a–5 of this title](/usc/42/1320a–5.md).
    - (B) **Notices of substandard care—** If a [State](/usc/42/619.md?p=5) finds that—
      - (i) a provider of home or community care has provided care of substandard quality with respect to an individual, the [State](/usc/42/619.md?p=5) shall make a reasonable effort to notify promptly (I) an immediate family member of each such individual and (II) individuals receiving home or community care from that provider under this subchapter, or
      - (ii) a community care setting is substandard, the [State](/usc/42/619.md?p=5) shall make a reasonable effort to notify promptly (I) individuals receiving community care in that setting, and (II) immediate family members of such individuals.
    - (C) **Access to fraud control units—** Each [State](/usc/42/619.md?p=5) shall provide its [State](/usc/42/619.md?p=5) medicaid fraud and [abuse](/usc/42/1397j.md?p=1) control unit (established under [section 1396b(q) of this title](/usc/42/1396b.md?p=q)) with access to all information of the [State agency](/usc/42/629a.md?p=a-3) responsible for surveys, reviews, and certifications under this subsection.
- (j) **Enforcement process for providers of community care—**
  - (1) **State authority—**
    - (A) **In general—** If a [State](/usc/42/619.md?p=5) finds, on the basis of a review under [subsection (i)(2)](#i-2) or otherwise, that a provider of home or community care no longer meets the requirements of this section, the [State](/usc/42/619.md?p=5) may terminate the provider’s participation under the [State](/usc/42/619.md?p=5) plan and may provide in addition for a civil money penalty. Nothing in this subparagraph shall be construed as restricting the remedies available to a [State](/usc/42/619.md?p=5) to remedy a provider’s deficiencies. If the [State](/usc/42/619.md?p=5) finds that a provider meets such requirements but, as of a previous period, did not meet such requirements, the [State](/usc/42/619.md?p=5) may provide for a civil money penalty under [paragraph (2)(A)](#j-2-A) for the period during which it finds that the provider was not in compliance with such requirements.
    - (B) **Civil money penalty—**
      - (i) **In general—** Each [State](/usc/42/619.md?p=5) shall establish by law (whether statute or regulation) at least the following remedy: A civil money penalty assessed and collected, with interest, for each day in which the provider is or was out of compliance with a requirement of this section. Funds collected by a [State](/usc/42/619.md?p=5) as a result of imposition of such a penalty (or as a result of the imposition by the [State](/usc/42/619.md?p=5) of a civil money penalty under [subsection (i)(3)(A)](#i-3-A)) may be applied to reimbursement of individuals for personal funds lost due to a failure of home or community care providers to meet the requirements of this section. The [State](/usc/42/619.md?p=5) also shall specify criteria, as to when and how this remedy is to be applied and the amounts of any penalties. Such criteria shall be designed so as to minimize the time between the identification of [violations](/usc/42/2000e–16a.md?p=c) and final imposition of the penalties and shall provide for the imposition of incrementally more severe penalties for repeated or uncorrected deficiencies.
      - (ii) **Deadline and guidance—** Each [State](/usc/42/619.md?p=5) which elects to provide home and community care under this section must establish the civil money penalty remedy described in [clause (i)](#j-1-B-i) applicable to all providers of community care covered under this section. The [Secretary](/usc/42/1301.md?p=a-6) shall provide, through regulations or otherwise by not later than July 1, 1990, guidance to [States](/usc/42/619.md?p=5) in establishing such remedy; but the failure of the [Secretary](/usc/42/1301.md?p=a-6) to provide such guidance shall not relieve a [State](/usc/42/619.md?p=5) of the responsibility for establishing such remedy.
  - (2) **Secretarial authority—**
    - (A) **For State providers—** With respect to a [State](/usc/42/619.md?p=5) provider of home or community care, the [Secretary](/usc/42/1301.md?p=a-6) shall have the authority and duties of a [State](/usc/42/619.md?p=5) under this subsection, except that the civil money penalty remedy described in [subparagraph (C)](#j-2-C) shall be substituted for the civil money remedy described in [paragraph (1)(B)(i)](#j-1-B-i).
    - (B) **Other providers—** With respect to any other provider of home or community care in a [State](/usc/42/619.md?p=5), if the [Secretary](/usc/42/1301.md?p=a-6) finds that a provider no longer meets a requirement of this section, the [Secretary](/usc/42/1301.md?p=a-6) may terminate the provider’s participation under the [State](/usc/42/619.md?p=5) plan and may provide, in addition, for a civil money penalty under [subparagraph (C)](#j-2-C). If the [Secretary](/usc/42/1301.md?p=a-6) finds that a provider meets such requirements but, as of a previous period, did not meet such requirements, the [Secretary](/usc/42/1301.md?p=a-6) may provide for a civil money penalty under [subparagraph (C)](#j-2-C) for the period during which the [Secretary](/usc/42/1301.md?p=a-6) finds that the provider was not in compliance with such requirements.
    - (C) **Civil money penalty—** If the [Secretary](/usc/42/1301.md?p=a-6) finds on the basis of a review under [subsection (i)(2)](#i-2) or otherwise that a home or community care provider no longer meets the requirements of this section, the [Secretary](/usc/42/1301.md?p=a-6) shall impose a civil money penalty in an amount not to exceed $10,000 for each day of noncompliance. The provisions of [section 1320a–7a of this title](/usc/42/1320a–7a.md) (other than subsections [(a)](#a) and [(b)](#b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under [section 1320a–7a(a) of this title](/usc/42/1320a–7a.md?p=a). The [Secretary](/usc/42/1301.md?p=a-6) shall specify criteria, as to when and how this remedy is to be applied and the amounts of any penalties. Such criteria shall be designed so as to minimize the time between the identification of [violations](/usc/42/2000e–16a.md?p=c) and final imposition of the penalties and shall provide for the imposition of incrementally more severe penalties for repeated or uncorrected deficiencies.
- (k) **Secretarial responsibilities—**
  - (1) **Publication of interim requirements—**
    - (A) **In general—** The [Secretary](/usc/42/1301.md?p=a-6) shall publish, by December 1, 1991, a proposed regulation that sets forth interim requirements, consistent with [subparagraph (B)](#k-1-B), for the provision of home and community care and for community care settings, [including](/usc/42/1301.md?p=b)—
      - (i) the requirements of [subsection (c)(2)](#c-2) (relating to comprehensive functional assessments, [including](/usc/42/1301.md?p=b) the use of assessment instruments), of [subsection (d)(2)(E)](#d-2-E) (relating to qualifications for qualified case managers), of [subsection (f)](#f) (relating to minimum requirements for home and community care), of [subsection (g)](#g) (relating to minimum requirements for small community care settings), and of [subsection (h)](#h) (relating to minimum requirements for large community care settings), and
      - (ii) survey protocols (for use under [subsection (i)(3)(A)](#i-3-A)) which relate to such requirements.
    - (B) **Minimum protections—** Interim requirements under [subparagraph (A)](#k-1-A) and final requirements under [paragraph (2)](#k-2) shall assure, through methods other than reliance on [State](/usc/42/619.md?p=5) licensure processes, that individuals receiving home and community care are protected from [neglect](/usc/42/1397j.md?p=16), physical and sexual [abuse](/usc/42/1397j.md?p=1), financial [exploitation](/usc/42/1397j.md?p=8), inappropriate involuntary restraint, and the provision of health care services by unqualified personnel in community care settings.
  - (2) **Development of final requirements—** The [Secretary](/usc/42/1301.md?p=a-6) shall develop, by not later than October 1, 1992—
    - (A) final requirements, consistent with [paragraph (1)(B)](#k-1-B), respecting the provision of appropriate, quality home and community care and respecting community care settings under this section, and [including](/usc/42/1301.md?p=b) at least the requirements referred to in [paragraph (1)(A)(i)](#k-1-A-i), and
    - (B) survey protocols and methods for evaluating and assuring the quality of community care settings.

    The [Secretary](/usc/42/1301.md?p=a-6) may, from time to time, revise such requirements, protocols, and methods.

  - (3) **No delegation to States—** The [Secretary](/usc/42/1301.md?p=a-6)’s authority under this subsection shall not be delegated to [States](/usc/42/619.md?p=5).
  - (4) **No prevention of more stringent requirements by States—** Nothing in this section shall be construed as preventing [States](/usc/42/619.md?p=5) from imposing requirements that are more stringent than the requirements published or developed by the [Secretary](/usc/42/1301.md?p=a-6) under this subsection.
- (l) **Waiver of Statewideness—** [States](/usc/42/619.md?p=5) may waive the requirement of [section 1396a(a)(1) of this title](/usc/42/1396a.md?p=a-1) (related to Statewideness) for a program of home and community care under this section.
- (m) **Limitation on amount of expenditures as medical assistance—**
  - (1) **Limitation on amount—** The amount of funds that may be expended as [medical assistance](/usc/42/1396d.md?p=a) to carry out the purposes of this section shall be for [fiscal year](/usc/42/619.md?p=3) 1991, $40,000,000, for [fiscal year](/usc/42/619.md?p=3) 1992, $70,000,000, for [fiscal year](/usc/42/619.md?p=3) 1993, $130,000,000, for [fiscal year](/usc/42/619.md?p=3) 1994, $160,000,000, and for [fiscal year](/usc/42/619.md?p=3) 1995, $180,000,000.
  - (2) **Assurance of entitlement to service—** A [State](/usc/42/619.md?p=5) which receives Federal [medical assistance](/usc/42/1396d.md?p=a) for expenditures for home and community care under this section must provide home and community care specified under the Individual Community Care Plan under [subsection (d)](#d) to individuals described in [subsection (b)](#b) for the duration of the election period, without regard to the amount of funds available to the [State](/usc/42/619.md?p=5) under [paragraph (1)](#m-1). For purposes of this paragraph, an election period is the period of 4 or more calendar quarters elected by the [State](/usc/42/619.md?p=5), and approved by the [Secretary](/usc/42/1301.md?p=a-6), for the provision of home and community care under this section.
  - (3) **Limitation on eligibility—** The [State](/usc/42/619.md?p=5) may limit eligibility for home and community care under this section during an election period under [paragraph (2)](#m-2) to reasonable classifications (based on age, degree of functional disability, and need for services).
  - (4) **Allocation of medical assistance—** The [Secretary](/usc/42/1301.md?p=a-6) shall establish a limitation on the amount of Federal [medical assistance](/usc/42/1396d.md?p=a) available to any [State](/usc/42/619.md?p=5) during the [State](/usc/42/619.md?p=5)’s election period under [paragraph (2)](#m-2). The limitation under this paragraph shall take into account the limitation under [paragraph (1)](#m-1) and the number of elderly individuals age 65 or over residing in such [State](/usc/42/619.md?p=5) in relation to the number of such elderly individuals in the [United States](/usc/42/1301.md?p=a-2) during 1990. For purposes of the previous sentence, elderly individuals shall, to the maximum extent practicable, be low-income elderly individuals.

## Footnotes

[^1]: So in original. Probably should not be capitalized.

## Source credit

(Aug. 14, 1935, ch. 531, title XIX, § 1929, as added Pub. L. 101–508, title IV, § 4711(b), Nov. 5, 1990, 104 Stat. 1388–174; amended Pub. L. 106–113, div. B, § 1000(a)(6) [title VI, § 608(v)], Nov. 29, 1999, 113 Stat. 1536, 1501A–398.)

## Notes

### Editorial Notes

### Codification

Pub. L. 101–508, title IV, § 4711(b)(1), Nov. 5, 1990, 104 Stat. 1388–174, which directed renumbering of section 1929 of the Social Security Act, act Aug. 14, 1935, as section 1930, could not be executed because there was no section 1929.

### Amendments

1999—Subsec. (c)(2)(E)(i), (ii). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(v)(1)], realigned margins.

Subsec. (k)(1)(A)(i). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(v)(2)], substituted “large community care settings),” for “large community care settings,”.

Subsec. (l). Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(v)(3)], substituted “Statewideness” for “State wideness”.

### Statutory Notes and Related Subsidiaries

### Effective Date

Section applicable to home and community care furnished on or after July 1, 1991, without regard to whether or not final regulations to carry out the amendments made by section 4711 of Pub. L. 101–508 have been promulgated by such date, see section 4711(e) of Pub. L. 101–508, set out as an Effective Date of 1990 Amendment note under section 1396a of this title.