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       Florida Senate - 2010                             CS for SB 1468
       By the Committee on Health and Human Services Appropriations;
       and Senator Peaden
       603-03260-10                                          20101468c1
    1                        A bill to be entitled                      
    2         An act relating to home and community-based services;
    3         amending s. 393.0661, F.S.; reducing the annual
    4         maximum expenditure to each client assigned by the
    5         Agency for Persons With Disabilities to tier one, tier
    6         two, tier three, and tier four level services;
    7         eliminating behavior assistant services in certain
    8         group homes as a deliverable service to eligible
    9         clients; creating s. 393.0662, F.S.; establishing the
   10         iBudget program for the delivery of home and
   11         community-based services; providing for amendment of
   12         current contracts to implement the iBudget system;
   13         providing for the phasing in of the program; requiring
   14         clients to use certain resources before using funds
   15         from their iBudget; requiring the agency to provide
   16         training for clients and evaluate and adopt rules with
   17         respect to the iBudget system; providing an effective
   18         date.
   20  Be It Enacted by the Legislature of the State of Florida:
   22         Section 1. Paragraphs (a), (b), (c), (d), and (f) of
   23  subsection (3) of section 393.0661, Florida Statutes, are
   24  amended to read:
   25         393.0661 Home and community-based services delivery system;
   26  comprehensive redesign.—The Legislature finds that the home and
   27  community-based services delivery system for persons with
   28  developmental disabilities and the availability of appropriated
   29  funds are two of the critical elements in making services
   30  available. Therefore, it is the intent of the Legislature that
   31  the Agency for Persons with Disabilities shall develop and
   32  implement a comprehensive redesign of the system.
   33         (3) The Agency for Health Care Administration, in
   34  consultation with the agency, shall seek federal approval and
   35  implement a four-tiered waiver system to serve eligible clients
   36  through the developmental disabilities and family and supported
   37  living waivers. The agency shall assign all clients receiving
   38  services through the developmental disabilities waiver to a tier
   39  based on a valid assessment instrument, client characteristics,
   40  and other appropriate assessment methods.
   41         (a) Tier one is limited to clients who have service needs
   42  that cannot be met in tier two, three, or four for intensive
   43  medical or adaptive needs and that are essential for avoiding
   44  institutionalization, or who possess behavioral problems that
   45  are exceptional in intensity, duration, or frequency and present
   46  a substantial risk of harm to themselves or others. Total annual
   47  expenditures under tier one may not exceed $120,000 per client
   48  each year.
   49         (b) Tier two is limited to clients whose service needs
   50  include a licensed residential facility and who are authorized
   51  to receive a moderate level of support for standard residential
   52  habilitation services or a minimal level of support for behavior
   53  focus residential habilitation services, or clients in supported
   54  living who receive more than 6 hours a day of in-home support
   55  services. Total annual expenditures under tier two may not
   56  exceed $49,500 $55,000 per client each year.
   57         (c) Tier three includes, but is not limited to, clients
   58  requiring residential placements, clients in independent or
   59  supported living situations, and clients who live in their
   60  family home. Total annual expenditures under tier three may not
   61  exceed $31,500 $35,000 per client each year.
   62         (d) Tier four is the family and supported living waiver and
   63  includes, but is not limited to, clients in independent or
   64  supported living situations and clients who live in their family
   65  home. Total annual expenditures under tier four may not exceed
   66  $13,313 $14,792 per client each year.
   67         (f) The agency shall seek federal waivers and amend
   68  contracts as necessary to make changes to services defined in
   69  federal waiver programs administered by the agency as follows:
   70         1. Supported living coaching services may not exceed 20
   71  hours per month for persons who also receive in-home support
   72  services.
   73         2. Limited support coordination services is the only type
   74  of support coordination service that may be provided to persons
   75  under the age of 18 who live in the family home.
   76         3. Personal care assistance services are limited to 180
   77  hours per calendar month and may not include rate modifiers.
   78  Additional hours may be authorized for persons who have
   79  intensive physical, medical, or adaptive needs if such hours are
   80  essential for avoiding institutionalization.
   81         4. Residential habilitation services are limited to 8 hours
   82  per day. Additional hours may be authorized for persons who have
   83  intensive medical or adaptive needs and if such hours are
   84  essential for avoiding institutionalization, or for persons who
   85  possess behavioral problems that are exceptional in intensity,
   86  duration, or frequency and present a substantial risk of harming
   87  themselves or others. This restriction shall be in effect until
   88  the four-tiered waiver system is fully implemented.
   89         5. Chore services, nonresidential support services, and
   90  homemaker services are eliminated. The agency shall expand the
   91  definition of in-home support services to allow the service
   92  provider to include activities previously provided in these
   93  eliminated services.
   94         6. Massage therapy, medication review, behavior assistant
   95  services provided in a standard or behavior-focus group home,
   96  and psychological assessment services are eliminated.
   97         7. The agency shall conduct supplemental cost plan reviews
   98  to verify the medical necessity of authorized services for plans
   99  that have increased by more than 8 percent during either of the
  100  2 preceding fiscal years.
  101         8. The agency shall implement a consolidated residential
  102  habilitation rate structure to increase savings to the state
  103  through a more cost-effective payment method and establish
  104  uniform rates for intensive behavioral residential habilitation
  105  services.
  106         9. Pending federal approval, the agency may extend current
  107  support plans for clients receiving services under Medicaid
  108  waivers for 1 year beginning July 1, 2007, or from the date
  109  approved, whichever is later. Clients who have a substantial
  110  change in circumstances which threatens their health and safety
  111  may be reassessed during this year in order to determine the
  112  necessity for a change in their support plan.
  113         10. The agency shall develop a plan to eliminate
  114  redundancies and duplications between in-home support services,
  115  companion services, personal care services, and supported living
  116  coaching by limiting or consolidating such services.
  117         11. The agency shall develop a plan to reduce the intensity
  118  and frequency of supported employment services to clients in
  119  stable employment situations who have a documented history of at
  120  least 3 years’ employment with the same company or in the same
  121  industry.
  122         Section 2. Section 393.0662, Florida Statutes, is created
  123  to read:
  124         393.0662Individual budgets for delivery of home and
  125  community-based services; iBudget system established.—The
  126  Legislature finds that improved financial management of the
  127  existing home and community-based Medicaid waiver program is
  128  necessary to avoid deficits that impede the provision of
  129  services to individuals who are on the waiting list for
  130  enrollment in the program. The Legislature further finds that
  131  clients and their families should have greater flexibility to
  132  choose the services that best allow them to live in their
  133  community within the limits of an established budget. Therefore,
  134  the Legislature intends that the agency, in consultation with
  135  the Agency for Health Care Administration, develop and implement
  136  a comprehensive redesign of the service delivery system using
  137  individual budgets as the basis for allocating the funds
  138  appropriated for the home and community-based services Medicaid
  139  waiver program among eligible enrolled clients. The service
  140  delivery system that uses individual budgets shall be called the
  141  iBudget system.
  142         (1)The agency shall establish an individual budget,
  143  referred to as an iBudget, for each individual served by the
  144  home and community-based services Medicaid waiver program. The
  145  funds appropriated to the agency shall be allocated through the
  146  iBudget system to eligible, Medicaid-enrolled clients. The
  147  iBudget system shall be designed to provide for: enhanced client
  148  choice within a specified service package; appropriate
  149  assessment strategies; an efficient consumer budgeting and
  150  billing process that includes reconciliation and monitoring
  151  components; a redefined role for support coordinators which
  152  avoids potential conflicts of interest; a flexible and
  153  streamlined service review process; and a methodology and
  154  process that ensures the equitable allocation of available funds
  155  to each client based on the client’s level of need, as
  156  determined by the variables in the allocation algorithm.
  157         (a)In developing each client’s iBudget, the agency shall
  158  use an allocation algorithm and methodology. The algorithm shall
  159  use variables that have been determined by the agency to have a
  160  statistically validated relationship to the client’s level of
  161  need for services provided through the home and community-based
  162  services Medicaid waiver program. The algorithm and methodology
  163  may consider individual characteristics, including, but not
  164  limited to, a client’s age and living situation, information
  165  from a formal assessment instrument that the agency determines
  166  is valid and reliable, and information from other assessment
  167  processes.
  168         (b)The allocation methodology shall provide the algorithm
  169  that determines the amount of funds allocated to a client’s
  170  iBudget. The agency may approve an increase in the amount of
  171  funds allocated, as determined by the algorithm, based on the
  172  client having:
  173         1.An extraordinary need that would place the health and
  174  safety of the client, the client’s caregiver, or the public in
  175  immediate, serious jeopardy unless the increase is approved. An
  176  extraordinary need may include, but is not limited to:
  177         a.A documented history of significant, potentially life
  178  threatening behaviors, such as recent attempts at suicide,
  179  arson, nonconsensual sexual behavior, or self-injurious behavior
  180  requiring medical attention;
  181         b.A complex medical condition that requires active
  182  intervention by a licensed nurse on an ongoing basis which
  183  cannot be taught or delegated to a nonlicensed person;
  184         c.A chronic co-morbid condition. As used in this
  185  subparagraph, the term “co-morbid condition” means a medical
  186  condition existing simultaneously but independently along with
  187  another medical condition in a patient; or
  188         d.A need for total physical assistance with activities
  189  such as eating, bathing, toileting, grooming, and personal
  190  hygiene.
  192  However, the presence of an extraordinary need alone does not
  193  warrant an increase in the amount of funds allocated to a
  194  client’s iBudget as determined by the algorithm.
  195         2.A significant need for one-time or temporary support or
  196  services that, if not provided, would place the health and
  197  safety of the client, the client’s caregiver, or the public in
  198  serious jeopardy, unless the increase, as determined by the
  199  total of the algorithm and any adjustments based on
  200  subparagraphs 1. and 3., is approved. A significant need may
  201  include, but is not limited to, the provision of environmental
  202  modifications, durable medical equipment, services to address
  203  the temporary loss of support from a caregiver, or special
  204  services or treatment for a serious temporary condition when the
  205  service or treatment is expected to ameliorate the underlying
  206  condition. As used in this subparagraph, the term “temporary”
  207  means a period of less than 12 continuous months.
  208         3.A significant increase in the need for services after
  209  the beginning of the service plan year which would place the
  210  health and safety of the client, the client’s caregiver, or the
  211  public in serious jeopardy because of substantial changes in the
  212  client’s circumstances, including, but not limited to, permanent
  213  or long-term loss or incapacity of a caregiver, loss of services
  214  authorized under the state Medicaid plan due to a change in age,
  215  or a significant change in medical or functional status which
  216  requires the provision of additional services on a permanent or
  217  long-term basis and which cannot be accommodated within the
  218  client’s current iBudget. As used in this subparagraph, the term
  219  “long-term” means a period of 12 or more continuous months.
  221  The agency shall reserve portions of the appropriation for the
  222  home and community-based services Medicaid waiver program for
  223  adjustments required pursuant to this paragraph and may use the
  224  services of an independent actuary in determining the amount of
  225  the portions to be reserved.
  226         (c)A client’s iBudget shall be the total of the amount
  227  determined by the algorithm and any additional funding provided
  228  pursuant to paragraph (a). A client’s annual expenditures for
  229  home and community-based services Medicaid waiver services may
  230  not exceed the limits of his or her iBudget. The total of a
  231  client’s projected annual iBudget expenditures may not exceed
  232  the agency’s appropriation for waiver services.
  233         (2)The Agency for Health Care Administration, in
  234  consultation with the agency, shall seek federal approval to
  235  amend current waivers, request a new waiver, and amend contracts
  236  as necessary to implement the iBudget system to serve eligible,
  237  enrolled clients through the home and community-based services
  238  Medicaid waiver program and the Consumer-Directed Care Plus
  239  Program.
  240         (3)The agency shall provide for the transition of all
  241  eligible, enrolled clients to the iBudget system. The agency may
  242  gradually phase in the iBudget system.
  243         (a)While the agency phases in the iBudget system, the
  244  agency may continue to serve eligible, enrolled clients under
  245  the four-tiered waiver system established under s. 393.065 while
  246  those clients await the transitionto the iBudget system.
  247         (b)The agency shall design the phase-in process to ensure
  248  that a client does not experience more than one-half of any
  249  expected overall increase or decrease to his or her existing
  250  annualized cost plan during the first year that the client is
  251  provided an iBudget due solely to the transition to the iBudget
  252  system.
  253         (4)A client must use all available services authorized
  254  under the state Medicaid plan, school-based services, private
  255  insurance, and other benefits and use any other resources that
  256  are available to the client before using funds from his or her
  257  iBudget to pay for support and services.
  258         (5)Rates for any or all services established under rules
  259  of the Agency for Health Care Administration shall be designated
  260  as the maximum rather than a fixed amount for individuals who
  261  receive an iBudget, except for services specifically identified
  262  in those rules which the agency determines are not appropriate
  263  for negotiation, including, but not limited to, residential
  264  habilitation services.
  265         (6)The agency shall ensure that clients and caregivers
  266  have access to training and education to inform them about the
  267  iBudget system and enhance their ability for self-direction.
  268  Such training shall be offered in a variety of formats and, at a
  269  minimum, shall address the policies and processes of the iBudget
  270  system; the roles and responsibilities of consumers, caregivers,
  271  waiver support coordinators, providers, and the agency;
  272  information available to help the client make decisions
  273  regarding the iBudget system; and examples of support and
  274  resources available in the community.
  275         (7)The agency shall collect data to evaluate the
  276  implementation and outcomes of the iBudget system.
  277         (8)The agency and the Agency for Health Care
  278  Administration may adopt rules specifying the allocation
  279  algorithm and methodology; criteria and processes for clients to
  280  access reserved funds for extraordinary needs, temporarily or
  281  permanently changed needs, and one-time needs; and processes and
  282  requirements for selection and review of services, development
  283  of support and cost plans, and management of the iBudget system
  284  as needed to administer this section.
  285         Section 3. This act shall take effect July 1, 2010.

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