December 14, 2019
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HB 5303

A bill to be entitled
2An act relating to the Agency for Persons with
3Disabilities; amending s. 393.065, F.S.; revising
4provisions relating to the order of priority for clients
5with developmental disabilities waiting for waiver
6services; extending the date for implementation for
7certain categories of clients; amending s. 393.0661, F.S.;
8specifying assessment instruments to be used for the
9delivery of home and community-based Medicaid waiver
10program services; revising provisions relating to
11assignment of clients to waiver tiers; directing the
12agency to eliminate behavior assistance services; reducing
13the geographic differential for Miami-Dade, Broward, Palm
14Beach, and Monroe Counties for residential habilitation
15services; creating s. 393.0662, F.S.; establishing the
16iBudget program for the delivery of home and community-
17based services; providing for amendment of current
18contracts to implement the iBudget system; providing for
19the phasing in of the program; requiring clients to use
20certain resources before using funds from their iBudget;
21requiring the agency to provide training for clients and
22evaluate and adopt rules with respect to the iBudget
23system; amending s. 393.125, F.S.; providing for hearings
24on Medicaid programs administered by the agency; providing
25an effective date.
27Be It Enacted by the Legislature of the State of Florida:
29     Section 1.  Subsection (5) of section 393.065, Florida
30Statutes, is amended to read:
31     393.065  Application and eligibility determination.-
32     (5)  Except as otherwise directed by law, beginning July 1,
332010, the agency shall assign and provide priority to clients
34waiting for waiver services in categories 1 and 2 and, beginning
35July 1, 2012, shall assign and provide priority to clients
36waiting for waiver services in categories 3, 4, 5, 6, and 7, in
37the following order:
38     (a)  Category 1, which includes clients deemed to be in
39crisis as described in rule.
40     (b)  Category 2, which includes children on the wait list
41who are from the child welfare system with an open case in the
42Department of Children and Family Services' statewide automated
43child welfare information system.
44     (c)  Category 3, which includes, but is not required to be
45limited to, clients:
46     1.  Whose caregiver has a documented condition that is
47expected to render the caregiver unable to provide care within
48the next 12 months and for whom a caregiver is required but no
49alternate caregiver is available;
50     2.  At substantial risk of incarceration or court
51commitment without supports;
52     3.  Whose documented behaviors or physical needs place them
53or their caregiver at risk of serious harm and other supports
54are not currently available to alleviate the situation; or
55     4.  Who are identified as ready for discharge within the
56next year from a state mental health hospital or skilled nursing
57facility and who require a caregiver but for whom no caregiver
58is available.
59     (d)  Category 4, which includes, but is not required to be
60limited to, clients whose caregivers are 70 years of age or
61older and for whom a caregiver is required but no alternate
62caregiver is available.
63     (e)  Category 5, which includes, but is not required to be
64limited to, clients who are expected to graduate within the next
6512 months from secondary school and need support to obtain or
66maintain competitive employment, or to pursue an accredited
67program of postsecondary education to which they have been
69     (f)  Category 6, which includes clients 21 years of age or
70older who do not meet the criteria for category 1, category 2,
71category 3, category 4, or category 5.
72     (g)  Category 7, which includes clients younger than 21
73years of age who do not meet the criteria for category 1,
74category 2, category 3, or category 4.
76Within categories 3, 4, 5, 6, and 7, the agency shall maintain a
77wait list of clients placed in the order of the date that the
78client is determined eligible for waiver services.
79     Section 2.  Paragraph (a) of subsection (1) and subsections
80(3), (4), and (5) of section 393.0661, Florida Statutes, are
81amended to read:
82     393.0661  Home and community-based services delivery
83system; comprehensive redesign.-The Legislature finds that the
84home and community-based services delivery system for persons
85with developmental disabilities and the availability of
86appropriated funds are two of the critical elements in making
87services available. Therefore, it is the intent of the
88Legislature that the Agency for Persons with Disabilities shall
89develop and implement a comprehensive redesign of the system.
90     (1)  The redesign of the home and community-based services
91system shall include, at a minimum, all actions necessary to
92achieve an appropriate rate structure, client choice within a
93specified service package, appropriate assessment strategies, an
94efficient billing process that contains reconciliation and
95monitoring components, a redefined role for support coordinators
96that avoids potential conflicts of interest, and ensures that
97family/client budgets are linked to levels of need.
98     (a)  The agency shall use either the Department of Children
99and Family Services' Individual Cost Guidelines or the agency's
100Questionnaire for Situational Information as an assessment
101instrument that is reliable and valid. The agency may contract
102with an external vendor or may use support coordinators to
103complete client assessments if it develops sufficient safeguards
104and training to ensure ongoing inter-rater reliability.
105     (3)  The Agency for Health Care Administration, in
106consultation with the agency, shall seek federal approval and
107implement a four-tiered waiver system to serve eligible clients
108through the developmental disabilities and family and supported
109living waivers. The agency shall assign all clients receiving
110services through the developmental disabilities waiver to a tier
111based on the Individual Cost Guidelines or the Questionnaire for
112Situational Information; a valid assessment instrument, client
113characteristics, including, but not limited to, age; and other
114appropriate assessment methods.
115     (a)  Tier one is limited to clients who have service needs
116that cannot be met in tier two, three, or four for intensive
117medical or adaptive needs and that are essential for avoiding
118institutionalization, or who possess behavioral problems that
119are exceptional in intensity, duration, or frequency and present
120a substantial risk of harm to themselves or others.
121     (b)  Tier two is limited to clients whose service needs
122include a licensed residential facility and who are authorized
123to receive a moderate level of support for standard residential
124habilitation services or a minimal level of support for behavior
125focus residential habilitation services, or clients in supported
126living who receive more than 6 hours a day of in-home support
127services. Total annual expenditures under tier two may not
128exceed $55,000 per client each year.
129     (c)  Tier three includes, but is not limited to, clients
130requiring residential placements, clients in independent or
131supported living situations, and clients who live in their
132family home. Total annual expenditures under tier three may not
133exceed $35,000 per client each year.
134     (d)  Tier four includes individuals who were enrolled in is
135the family and supported living waiver on July 1, 2007, who
136shall be assigned to this tier without the assessments required
137by this section. Tier four also and includes, but is not limited
138to, clients in independent or supported living situations and
139clients who live in their family home. Total annual expenditures
140under tier four may not exceed $14,792 per client each year.
141     (e)  The Agency for Health Care Administration shall also
142seek federal approval to provide a consumer-directed option for
143persons with developmental disabilities which corresponds to the
144funding levels in each of the waiver tiers. The agency shall
145implement the four-tiered waiver system beginning with tiers
146one, three, and four and followed by tier two. The agency and
147the Agency for Health Care Administration may adopt rules
148necessary to administer this subsection.
149     (f)  The agency shall seek federal waivers and amend
150contracts as necessary to make changes to services defined in
151federal waiver programs administered by the agency as follows:
152     1.  Supported living coaching services may not exceed 20
153hours per month for persons who also receive in-home support
155     2.  Limited support coordination services is the only type
156of support coordination service that may be provided to persons
157under the age of 18 who live in the family home.
158     3.  Personal care assistance services are limited to 180
159hours per calendar month and may not include rate modifiers.
160Additional hours may be authorized for persons who have
161intensive physical, medical, or adaptive needs if such hours are
162essential for avoiding institutionalization.
163     4.  Residential habilitation services are limited to 8
164hours per day. Additional hours may be authorized for persons
165who have intensive medical or adaptive needs and if such hours
166are essential for avoiding institutionalization, or for persons
167who possess behavioral problems that are exceptional in
168intensity, duration, or frequency and present a substantial risk
169of harming themselves or others. This restriction shall be in
170effect until the four-tiered waiver system is fully implemented.
171     5.  Chore services, nonresidential support services, and
172homemaker services are eliminated. The agency shall expand the
173definition of in-home support services to allow the service
174provider to include activities previously provided in these
175eliminated services.
176     6.  Massage therapy, medication review, behavior assistance
177services, and psychological assessment services are eliminated.
178     7.  The agency shall conduct supplemental cost plan reviews
179to verify the medical necessity of authorized services for plans
180that have increased by more than 8 percent during either of the
1812 preceding fiscal years.
182     8.  The agency shall implement a consolidated residential
183habilitation rate structure to increase savings to the state
184through a more cost-effective payment method and establish
185uniform rates for intensive behavioral residential habilitation
187     9.  Pending federal approval, the agency may extend current
188support plans for clients receiving services under Medicaid
189waivers for 1 year beginning July 1, 2007, or from the date
190approved, whichever is later. Clients who have a substantial
191change in circumstances which threatens their health and safety
192may be reassessed during this year in order to determine the
193necessity for a change in their support plan.
194     10.  The agency shall develop a plan to eliminate
195redundancies and duplications between in-home support services,
196companion services, personal care services, and supported living
197coaching by limiting or consolidating such services.
198     11.  The agency shall develop a plan to reduce the
199intensity and frequency of supported employment services to
200clients in stable employment situations who have a documented
201history of at least 3 years' employment with the same company or
202in the same industry.
203     (4)  Effective July 1, 2010, the geographic differential
204for Miami-Dade, Broward, and Palm Beach Counties for residential
205habilitation services shall be 4.5 7.5 percent.
206     (5)(a)  Effective July 1, 2010, the geographic differential
207for Monroe County for residential habilitation services shall be
20815 20 percent.
209     (b)  Effective July 1, 2011, the geographic differential
210for Monroe County for residential habilitation services shall be
21110 percent.
212     Section 3.  Section 393.0662, Florida Statutes, is created
213to read:
214     393.0662  Individual budgets for delivery of home and
215community-based services; iBudget system established.-The
216Legislature finds that improved financial management of the
217existing home and community-based Medicaid waiver program is
218necessary to avoid deficits that impede the provision of
219services to individuals who are on the waiting list for
220enrollment in the program. The Legislature further finds that
221clients and their families should have greater flexibility to
222choose the services that best allow them to live in their
223community within the limits of an established budget. Therefore,
224the Legislature intends that the agency, in consultation with
225the Agency for Health Care Administration, develop and implement
226a comprehensive redesign of the service delivery system using
227individual budgets as the basis for allocating the funds
228appropriated for the home and community-based services Medicaid
229waiver program among eligible enrolled clients. The service
230delivery system that uses individual budgets shall be called the
231iBudget system.
232     (1)  The agency shall establish an individual budget,
233referred to as an iBudget, for each individual served by the
234home and community-based services Medicaid waiver program. The
235funds appropriated to the agency shall be allocated through the
236iBudget system to eligible, Medicaid-enrolled clients. The
237iBudget system shall be designed to provide for: enhanced client
238choice within a specified service package; appropriate
239assessment strategies; an efficient consumer budgeting and
240billing process that includes reconciliation and monitoring
241components; a redefined role for support coordinators that
242avoids potential conflicts of interest; a flexible and
243streamlined service review process; and a methodology and
244process that ensures the equitable allocation of available funds
245to each client based on the client's level of need, as
246determined by the variables in the allocation algorithm.
247     (a)  In developing each client's iBudget, the agency shall
248use an allocation algorithm and methodology. The algorithm shall
249use variables that have been determined by the agency to have a
250statistically validated relationship to the client's level of
251need for services provided through the home and community-based
252services Medicaid waiver program. The algorithm and methodology
253may consider individual characteristics, including, but not
254limited to, a client's age and living situation, information
255from a formal assessment instrument that the agency determines
256is valid and reliable, and information from other assessment
258     (b)  The allocation methodology shall provide the algorithm
259that determines the amount of funds allocated to a client's
260iBudget. The agency may approve an increase in the amount of
261funds allocated, as determined by the algorithm, based on the
262client having:
263     1.  An extraordinary need that would place the health and
264safety of the client, the client's caregiver, or the public in
265immediate, serious jeopardy unless the increase is approved. An
266extraordinary need may include, but is not limited to:
267     a.  A documented history of significant, potentially life-
268threatening behaviors, such as recent attempts at suicide,
269arson, nonconsensual sexual behavior, or self-injurious behavior
270requiring medical attention;
271     b.  A complex medical condition that requires active
272intervention by a licensed nurse on an ongoing basis that cannot
273be taught or delegated to a nonlicensed person;
274     c.  A chronic co-morbid condition. As used in this
275subparagraph, the term "co-morbid condition" means a medical
276condition existing simultaneously but independently with another
277medical condition in a patient; or
278     d.  A need for total physical assistance with activities
279such as eating, bathing, toileting, grooming, and personal
282However, the presence of an extraordinary need alone does not
283warrant an increase in the amount of funds allocated to a
284client's iBudget as determined by the algorithm.
285     2.  A significant need for one-time or temporary support or
286services that, if not provided, would place the health and
287safety of the client, the client's caregiver, or the public in
288serious jeopardy, unless the increase, as determined by the
289total of the algorithm and any adjustments based on
290subparagraphs 1. and 3., is approved. A significant need may
291include, but is not limited to, the provision of environmental
292modifications, durable medical equipment, services to address
293the temporary loss of support from a caregiver, or special
294services or treatment for a serious temporary condition when the
295service or treatment is expected to ameliorate the underlying
296condition. As used in this subparagraph, the term "temporary"
297means a period of fewer than 12 continuous months.
298     3.  A significant increase in the need for services after
299the beginning of the service plan year that would place the
300health and safety of the client, the client's caregiver, or the
301public in serious jeopardy because of substantial changes in the
302client's circumstances, including, but not limited to, permanent
303or long-term loss or incapacity of a caregiver, loss of services
304authorized under the state Medicaid plan due to a change in age,
305or a significant change in medical or functional status which
306requires the provision of additional services on a permanent or
307long-term basis that cannot be accommodated within the client's
308current iBudget. As used in this subparagraph, the term "long-
309term" means a period of 12 or more continuous months.
311The agency shall reserve portions of the appropriation for the
312home and community-based services Medicaid waiver program for
313adjustments required pursuant to this paragraph and may use the
314services of an independent actuary in determining the amount of
315the portions to be reserved.
316     (c)  A client's iBudget shall be the total of the amount
317determined by the algorithm and any additional funding provided
318pursuant to paragraph (a). A client's annual expenditures for
319home and community-based services Medicaid waiver services may
320not exceed the limits of his or her iBudget. The total of a
321client's projected annual iBudget expenditures may not exceed
322the agency's appropriation for waiver services.
323     (2)  The Agency for Health Care Administration, in
324consultation with the agency, shall seek federal approval to
325amend current waivers, request a new waiver, and amend contracts
326as necessary to implement the iBudget system to serve eligible,
327enrolled clients through the home and community-based services
328Medicaid waiver program and the Consumer-Directed Care Plus
330     (3)  The agency shall transition all eligible, enrolled
331clients to the iBudget system. The agency may gradually phase in
332the iBudget system.
333     (a)  While the agency phases in the iBudget system, the
334agency may continue to serve eligible, enrolled clients under
335the four-tiered waiver system established under s. 393.065 while
336those clients await transitioning to the iBudget system.
337     (b)  The agency shall design the phase-in process to ensure
338that a client does not experience more than one-half of any
339expected overall increase or decrease to his or her existing
340annualized cost plan during the first year that the client is
341provided an iBudget due solely to the transition to the iBudget
343     (4)  A client must use all available services authorized
344under the state Medicaid plan, school-based services, private
345insurance and other benefits, and any other resources that may
346be available to the client before using funds from his or her
347iBudget to pay for support and services.
348     (5)  Rates for any or all services established under rules
349of the Agency for Health Care Administration shall be designated
350as the maximum rather than a fixed amount for individuals who
351receive an iBudget, except for services specifically identified
352in those rules that the agency determines are not appropriate
353for negotiation, which may include, but are not limited to,
354residential habilitation services.
355     (6)  The agency shall ensure that clients and caregivers
356have access to training and education to inform them about the
357iBudget system and enhance their ability for self-direction.
358Such training shall be offered in a variety of formats and at a
359minimum shall address the policies and processes of the iBudget
360system; the roles and responsibilities of consumers, caregivers,
361waiver support coordinators, providers, and the agency;
362information available to help the client make decisions
363regarding the iBudget system; and examples of support and
364resources available in the community.
365     (7)  The agency shall collect data to evaluate the
366implementation and outcomes of the iBudget system.
367     (8)  The agency and the Agency for Health Care
368Administration may adopt rules specifying the allocation
369algorithm and methodology; criteria and processes for clients to
370access reserved funds for extraordinary needs, temporarily or
371permanently changed needs, and one-time needs; and processes and
372requirements for selection and review of services, development
373of support and cost plans, and management of the iBudget system
374as needed to administer this section.
375     Section 4.  Subsection (1) of section 393.125, Florida
376Statutes, is amended to read:
377     393.125  Hearing rights.-
379     (a)  For Medicaid programs administered by the agency, any
380developmental services applicant or client, or his or her
381parent, guardian advocate, or authorized representative, may
382request a hearing in accordance with federal law and rules
383applicable to Medicaid cases and has the right to request an
384administrative hearing pursuant to ss. 120.569 and 120.57. These
385hearings shall be provided by the Department of Children and
386Family Services pursuant to s. 409.285 and shall follow
387procedures consistent with federal law and rules applicable to
388Medicaid cases.
389     (b)(a)  Any other developmental services applicant or
390client, or his or her parent, guardian, guardian advocate, or
391authorized representative, who has any substantial interest
392determined by the agency, has the right to request an
393administrative hearing pursuant to ss. 120.569 and 120.57, which
394shall be conducted pursuant to s. 120.57(1), (2), or (3).
395     (c)(b)  Notice of the right to an administrative hearing
396shall be given, both verbally and in writing, to the applicant
397or client, and his or her parent, guardian, guardian advocate,
398or authorized representative, at the same time that the agency
399gives the applicant or client notice of the agency's action. The
400notice shall be given, both verbally and in writing, in the
401language of the client or applicant and in English.
402     (d)(c)  A request for a hearing under this section shall be
403made to the agency, in writing, within 30 days after of the
404applicant's or client's receipt of the notice.
405     Section 5.  This act shall take effect July 1, 2010.

CODING: Words stricken are deletions; words underlined are additions.
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