December 11, 2019
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HB 5303

1
A bill to be entitled
2An act relating to the Agency for Persons with
3Disabilities; amending s. 393.0661, F.S.; specifying
4assessment instruments to be used for the delivery of home
5and community-based Medicaid waiver program services;
6revising provisions relating to assignment of clients to
7waiver tiers; providing for tier one, tier two, tier
8three, and tier four annual expenditure caps; creating s.
9393.0662, F.S.; establishing the iBudget program for the
10delivery of home and community-based services; providing
11for amendment of current contracts to implement the
12iBudget system; providing for the phasing in of the
13program; requiring clients to use certain resources before
14using funds from their iBudget; requiring the agency to
15provide training for clients and evaluate and adopt rules
16with respect to the iBudget system; amending s. 393.125,
17F.S.; providing for hearings on Medicaid programs
18administered by the agency; creating the Services for
19Children with Developmental Disabilities Task Force;
20requiring the task force to develop recommendations and a
21plan for the creation of, and enrollment in, the
22Developmental Disabilities Savings Program; providing for
23membership of the task force; requiring the Agency for
24Persons with Disabilities to provide administrative
25support to the task force; providing for per diem and
26travel expenses for task force members; requiring the task
27force to submit its plan and recommendations to the
28Legislature; providing for abolishment of the task force;
29providing an effective date.
30
31Be It Enacted by the Legislature of the State of Florida:
32
33     Section 1.  Subsections (1) and (3) of section 393.0661,
34Florida Statutes, are amended to read:
35     393.0661  Home and community-based services delivery
36system; comprehensive redesign.-The Legislature finds that the
37home and community-based services delivery system for persons
38with developmental disabilities and the availability of
39appropriated funds are two of the critical elements in making
40services available. Therefore, it is the intent of the
41Legislature that the Agency for Persons with Disabilities shall
42develop and implement a comprehensive redesign of the system.
43     (1)  The redesign of the home and community-based services
44system shall include, at a minimum, all actions necessary to
45achieve an appropriate rate structure, client choice within a
46specified service package, appropriate assessment strategies, an
47efficient billing process that contains reconciliation and
48monitoring components, and a redefined role for support
49coordinators that avoids potential conflicts of interest, and
50ensures that family/client budgets are linked to levels of need.
51     (a)  The agency shall use an assessment instrument that the
52agency deems to be is reliable and valid, including, but not
53limited to, the Department of Children and Family Services'
54Individual Cost Guidelines or the agency's Questionnaire for
55Situational Information. The agency may contract with an
56external vendor or may use support coordinators to complete
57client assessments if it develops sufficient safeguards and
58training to ensure ongoing inter-rater reliability.
59     (b)  The agency, with the concurrence of the Agency for
60Health Care Administration, may contract for the determination
61of medical necessity and establishment of individual budgets.
62     (3)  The Agency for Health Care Administration, in
63consultation with the agency, shall seek federal approval and
64implement a four-tiered waiver system to serve eligible clients
65through the developmental disabilities and family and supported
66living waivers. The agency shall assign all clients receiving
67services through the developmental disabilities waiver to a tier
68based on the Department of Children and Family Services'
69Individual Cost Guidelines, the agency's Questionnaire for
70Situational Information, or another such assessment instrument
71deemed to be valid and reliable by the agency; a valid
72assessment instrument, client characteristics, including, but
73not limited to, age; and other appropriate assessment methods.
74     (a)  Tier one is limited to clients who have service needs
75that cannot be met in tier two, three, or four for intensive
76medical or adaptive needs and that are essential for avoiding
77institutionalization, or who possess behavioral problems that
78are exceptional in intensity, duration, or frequency and present
79a substantial risk of harm to themselves or others. Total annual
80expenditures under tier one may not exceed $150,000 per client
81each year, provided that expenditures for clients in tier one
82with a documented medical necessity requiring intensive
83behavioral residential habilitation services, intensive
84behavioral residential habilitation services with medical needs,
85or special medical home care, as provided in the Developmental
86Disabilities Waiver Services Coverage and Limitations Handbook,
87are not subject to the $150,000 limit on annual expenditures.
88     (b)  Tier two is limited to clients whose service needs
89include a licensed residential facility and who are authorized
90to receive a moderate level of support for standard residential
91habilitation services or a minimal level of support for behavior
92focus residential habilitation services, or clients in supported
93living who receive more than 6 hours a day of in-home support
94services. Total annual expenditures under tier two may not
95exceed $53,625 $55,000 per client each year.
96     (c)  Tier three includes, but is not limited to, clients
97requiring residential placements, clients in independent or
98supported living situations, and clients who live in their
99family home. Total annual expenditures under tier three may not
100exceed $34,125 $35,000 per client each year.
101     (d)  Tier four includes individuals who were enrolled in is
102the family and supported living waiver on July 1, 2007, who
103shall be assigned to this tier without the assessments required
104by this section. Tier four also and includes, but is not limited
105to, clients in independent or supported living situations and
106clients who live in their family home. Total annual expenditures
107under tier four may not exceed $14,422 $14,792 per client each
108year.
109     (e)  The Agency for Health Care Administration shall also
110seek federal approval to provide a consumer-directed option for
111persons with developmental disabilities which corresponds to the
112funding levels in each of the waiver tiers. The agency shall
113implement the four-tiered waiver system beginning with tiers
114one, three, and four and followed by tier two. The agency and
115the Agency for Health Care Administration may adopt rules
116necessary to administer this subsection.
117     (f)  The agency shall seek federal waivers and amend
118contracts as necessary to make changes to services defined in
119federal waiver programs administered by the agency as follows:
120     1.  Supported living coaching services may not exceed 20
121hours per month for persons who also receive in-home support
122services.
123     2.  Limited support coordination services is the only type
124of support coordination service that may be provided to persons
125under the age of 18 who live in the family home.
126     3.  Personal care assistance services are limited to 180
127hours per calendar month and may not include rate modifiers.
128Additional hours may be authorized for persons who have
129intensive physical, medical, or adaptive needs if such hours are
130essential for avoiding institutionalization.
131     4.  Residential habilitation services are limited to 8
132hours per day. Additional hours may be authorized for persons
133who have intensive medical or adaptive needs and if such hours
134are essential for avoiding institutionalization, or for persons
135who possess behavioral problems that are exceptional in
136intensity, duration, or frequency and present a substantial risk
137of harming themselves or others. This restriction shall be in
138effect until the four-tiered waiver system is fully implemented.
139     5.  Chore services, nonresidential support services, and
140homemaker services are eliminated. The agency shall expand the
141definition of in-home support services to allow the service
142provider to include activities previously provided in these
143eliminated services.
144     6.  Massage therapy, medication review, and psychological
145assessment services are eliminated.
146     7.  The agency shall conduct supplemental cost plan reviews
147to verify the medical necessity of authorized services for plans
148that have increased by more than 8 percent during either of the
1492 preceding fiscal years.
150     8.  The agency shall implement a consolidated residential
151habilitation rate structure to increase savings to the state
152through a more cost-effective payment method and establish
153uniform rates for intensive behavioral residential habilitation
154services.
155     9.  Pending federal approval, the agency may extend current
156support plans for clients receiving services under Medicaid
157waivers for 1 year beginning July 1, 2007, or from the date
158approved, whichever is later. Clients who have a substantial
159change in circumstances which threatens their health and safety
160may be reassessed during this year in order to determine the
161necessity for a change in their support plan.
162     10.  The agency shall develop a plan to eliminate
163redundancies and duplications between in-home support services,
164companion services, personal care services, and supported living
165coaching by limiting or consolidating such services.
166     11.  The agency shall develop a plan to reduce the
167intensity and frequency of supported employment services to
168clients in stable employment situations who have a documented
169history of at least 3 years' employment with the same company or
170in the same industry.
171     Section 2.  Section 393.0662, Florida Statutes, is created
172to read:
173     393.0662  Individual budgets for delivery of home and
174community-based services; iBudget system established.-The
175Legislature finds that improved financial management of the
176existing home and community-based Medicaid waiver program is
177necessary to avoid deficits that impede the provision of
178services to individuals who are on the waiting list for
179enrollment in the program. The Legislature further finds that
180clients and their families should have greater flexibility to
181choose the services that best allow them to live in their
182community within the limits of an established budget. Therefore,
183the Legislature intends that the agency, in consultation with
184the Agency for Health Care Administration, develop and implement
185a comprehensive redesign of the service delivery system using
186individual budgets as the basis for allocating the funds
187appropriated for the home and community-based services Medicaid
188waiver program among eligible enrolled clients. The service
189delivery system that uses individual budgets shall be called the
190iBudget system.
191     (1)  The agency shall establish an individual budget,
192referred to as an iBudget, for each individual served by the
193home and community-based services Medicaid waiver program. The
194funds appropriated to the agency shall be allocated through the
195iBudget system to eligible, Medicaid-enrolled clients. The
196iBudget system shall be designed to provide for: enhanced client
197choice within a specified service package; appropriate
198assessment strategies; an efficient consumer budgeting and
199billing process that includes reconciliation and monitoring
200components; a redefined role for support coordinators that
201avoids potential conflicts of interest; a flexible and
202streamlined service review process; and a methodology and
203process that ensures the equitable allocation of available funds
204to each client based on the client's level of need, as
205determined by the variables in the allocation algorithm.
206     (a)  In developing each client's iBudget, the agency shall
207use an allocation algorithm and methodology. The algorithm shall
208use variables that have been determined by the agency to have a
209statistically validated relationship to the client's level of
210need for services provided through the home and community-based
211services Medicaid waiver program. The algorithm and methodology
212may consider individual characteristics, including, but not
213limited to, a client's age and living situation, information
214from a formal assessment instrument that the agency determines
215is valid and reliable, and information from other assessment
216processes.
217     (b)  The allocation methodology shall provide the algorithm
218that determines the amount of funds allocated to a client's
219iBudget. The agency may approve an increase in the amount of
220funds allocated, as determined by the algorithm, based on the
221client having one or more of the following needs that cannot be
222accommodated within the funding as determined by the algorithm
223and having no other resources, supports, or services available
224to meet the need:
225     1.  An extraordinary need that would place the health and
226safety of the client, the client's caregiver, or the public in
227immediate, serious jeopardy unless the increase is approved. An
228extraordinary need may include, but is not limited to:
229     a.  A documented history of significant, potentially life-
230threatening behaviors, such as recent attempts at suicide,
231arson, nonconsensual sexual behavior, or self-injurious behavior
232requiring medical attention;
233     b.  A complex medical condition that requires active
234intervention by a licensed nurse on an ongoing basis that cannot
235be taught or delegated to a nonlicensed person;
236     c.  A chronic co-morbid condition. As used in this
237subparagraph, the term "co-morbid condition" means a medical
238condition existing simultaneously but independently with another
239medical condition in a patient; or
240     d.  A need for total physical assistance with activities
241such as eating, bathing, toileting, grooming, and personal
242hygiene.
243
244However, the presence of an extraordinary need alone does not
245warrant an increase in the amount of funds allocated to a
246client's iBudget as determined by the algorithm.
247     2.  A significant need for one-time or temporary support or
248services that, if not provided, would place the health and
249safety of the client, the client's caregiver, or the public in
250serious jeopardy, unless the increase is approved. A significant
251need may include, but is not limited to, the provision of
252environmental modifications, durable medical equipment, services
253to address the temporary loss of support from a caregiver, or
254special services or treatment for a serious temporary condition
255when the service or treatment is expected to ameliorate the
256underlying condition. As used in this subparagraph, the term
257"temporary" means a period of fewer than 12 continuous months.
258However, the presence of such significant need for one-time or
259temporary supports or services alone does not warrant an
260increase in the amount of funds allocated to a client's iBudget
261as determined by the algorithm.
262     3.  A significant increase in the need for services after
263the beginning of the service plan year that would place the
264health and safety of the client, the client's caregiver, or the
265public in serious jeopardy because of substantial changes in the
266client's circumstances, including, but not limited to, permanent
267or long-term loss or incapacity of a caregiver, loss of services
268authorized under the state Medicaid plan due to a change in age,
269or a significant change in medical or functional status which
270requires the provision of additional services on a permanent or
271long-term basis that cannot be accommodated within the client's
272current iBudget. As used in this subparagraph, the term "long-
273term" means a period of 12 or more continuous months. However,
274such significant increase in need for services of a permanent or
275long-term nature alone does not warrant an increase in the
276amount of funds allocated to a client's iBudget as determined by
277the algorithm.
278
279The agency shall reserve portions of the appropriation for the
280home and community-based services Medicaid waiver program for
281adjustments required pursuant to this paragraph and may use the
282services of an independent actuary in determining the amount of
283the portions to be reserved.
284     (c)  A client's iBudget shall be the total of the amount
285determined by the algorithm and any additional funding provided
286pursuant to paragraph (b). A client's annual expenditures for
287home and community-based services Medicaid waiver services may
288not exceed the limits of his or her iBudget. The total of all
289clients' projected annual iBudget expenditures may not exceed
290the agency's appropriation for waiver services.
291     (2)  The Agency for Health Care Administration, in
292consultation with the agency, shall seek federal approval to
293amend current waivers, request a new waiver, and amend contracts
294as necessary to implement the iBudget system to serve eligible,
295enrolled clients through the home and community-based services
296Medicaid waiver program and the Consumer-Directed Care Plus
297Program.
298     (3)  The agency shall transition all eligible, enrolled
299clients to the iBudget system. The agency may gradually phase in
300the iBudget system.
301     (a)  While the agency phases in the iBudget system, the
302agency may continue to serve eligible, enrolled clients under
303the four-tiered waiver system established under s. 393.065 while
304those clients await transitioning to the iBudget system.
305     (b)  The agency shall design the phase-in process to ensure
306that a client does not experience more than one-half of any
307expected overall increase or decrease to his or her existing
308annualized cost plan during the first year that the client is
309provided an iBudget due solely to the transition to the iBudget
310system.
311     (4)  A client must use all available services authorized
312under the state Medicaid plan, school-based services, private
313insurance and other benefits, and any other resources that may
314be available to the client before using funds from his or her
315iBudget to pay for support and services.
316     (5)  The service limitations in s. 393.0661(3)(f)1., 2.,
317and 3. do not apply to the iBudget system.
318     (6)  Rates for any or all services established under rules
319of the Agency for Health Care Administration shall be designated
320as the maximum rather than a fixed amount for individuals who
321receive an iBudget, except for services specifically identified
322in those rules that the agency determines are not appropriate
323for negotiation, which may include, but are not limited to,
324residential habilitation services.
325     (7)  The agency shall ensure that clients and caregivers
326have access to training and education to inform them about the
327iBudget system and enhance their ability for self-direction.
328Such training shall be offered in a variety of formats and at a
329minimum shall address the policies and processes of the iBudget
330system; the roles and responsibilities of consumers, caregivers,
331waiver support coordinators, providers, and the agency;
332information available to help the client make decisions
333regarding the iBudget system; and examples of support and
334resources available in the community.
335     (8)  The agency shall collect data to evaluate the
336implementation and outcomes of the iBudget system.
337     (9)  The agency and the Agency for Health Care
338Administration may adopt rules specifying the allocation
339algorithm and methodology; criteria and processes for clients to
340access reserved funds for extraordinary needs, temporarily or
341permanently changed needs, and one-time needs; and processes and
342requirements for selection and review of services, development
343of support and cost plans, and management of the iBudget system
344as needed to administer this section.
345     Section 3.  Subsection (1) of section 393.125, Florida
346Statutes, is amended to read:
347     393.125  Hearing rights.-
348     (1)  REVIEW OF AGENCY DECISIONS.-
349     (a)  For Medicaid programs administered by the agency, any
350developmental services applicant or client, or his or her
351parent, guardian advocate, or authorized representative, may
352request a hearing in accordance with federal law and rules
353applicable to Medicaid cases and has the right to request an
354administrative hearing pursuant to ss. 120.569 and 120.57. These
355hearings shall be provided by the Department of Children and
356Family Services pursuant to s. 409.285 and shall follow
357procedures consistent with federal law and rules applicable to
358Medicaid cases.
359     (b)(a)  Any other developmental services applicant or
360client, or his or her parent, guardian, guardian advocate, or
361authorized representative, who has any substantial interest
362determined by the agency, has the right to request an
363administrative hearing pursuant to ss. 120.569 and 120.57, which
364shall be conducted pursuant to s. 120.57(1), (2), or (3).
365     (c)(b)  Notice of the right to an administrative hearing
366shall be given, both verbally and in writing, to the applicant
367or client, and his or her parent, guardian, guardian advocate,
368or authorized representative, at the same time that the agency
369gives the applicant or client notice of the agency's action. The
370notice shall be given, both verbally and in writing, in the
371language of the client or applicant and in English.
372     (d)(c)  A request for a hearing under this section shall be
373made to the agency, in writing, within 30 days after of the
374applicant's or client's receipt of the notice.
375     Section 4.  Services for Children with Developmental
376Disabilities Task Force.-The Services for Children with
377Developmental Disabilities Task Force is created to make
378recommendations and develop a plan for the creation of, and
379enrollment in, the Developmental Disabilities Savings Program.
380     (1)  The task force shall consist of the following members:
381     (a)  A member of the House of Representatives appointed by
382the Speaker of the House of Representatives.
383     (b)  A member of the Senate appointed by the President of
384the Senate.
385     (c)  The director of the Agency for Persons with
386Disabilities.
387     (d)  The director of the Division of Vocational
388Rehabilitation.
389     (e)  The executive director of the State Board of
390Administration.
391     (f)  The Commissioner of Education.
392     (g)  The executive director of The Arc of Florida.
393     (h)  An Arc of Florida family board member appointed by the
394executive director of The Arc of Florida.
395     (i)  The chair of the Family Care Council Florida.
396     (j)  A parent representative from the Family Care Council
397Florida appointed by the chair of the Family Care Council
398Florida.
399     (2)  The Agency for Persons with Disabilities shall provide
400administrative support to the task force.
401     (3)  Members of the task force shall serve without
402compensation but are entitled to reimbursement for per diem and
403travel expenses as provided in s. 112.061, Florida Statutes.
404     (4)  The task force shall submit its recommendations and
405plan to the President of the Senate and the Speaker of the House
406of Representatives when it has completed its task or April 2,
4072012, whichever occurs first.
408     (5)  The task force shall continue until enrollment in the
409Developmental Disabilities Savings Program has commenced, at
410which time the task force is abolished or June 31, 2013,
411whichever occurs first.
412     Section 5.  This act shall take effect July 1, 2010.
413


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