HB 5303

1	A bill to be entitled
2	An act relating to the Agency for Persons with
3	Disabilities; amending s. 393.065, F.S.; revising
4	provisions relating to the order of priority for clients
5	with developmental disabilities waiting for waiver
6	services; extending the date for implementation for
7	certain categories of clients; amending s. 393.0661, F.S.;
8	specifying assessment instruments to be used for the
9	delivery of home and community-based Medicaid waiver
10	program services; revising provisions relating to
11	assignment of clients to waiver tiers; directing the
12	agency to eliminate behavior assistance services; reducing
13	the geographic differential for Miami-Dade, Broward, Palm
14	Beach, and Monroe Counties for residential habilitation
15	services; creating s. 393.0662, F.S.; establishing the
16	iBudget program for the delivery of home and community-
17	based services; providing for amendment of current
18	contracts to implement the iBudget system; providing for
19	the phasing in of the program; requiring clients to use
20	certain resources before using funds from their iBudget;
21	requiring the agency to provide training for clients and
22	evaluate and adopt rules with respect to the iBudget
23	system; amending s. 393.125, F.S.; providing for hearings
24	on Medicaid programs administered by the agency; providing
25	an effective date.
26
27	Be It Enacted by the Legislature of the State of Florida:
28
29	Section 1.  Subsection (5) of section 393.065, Florida
30	Statutes, is amended to read:
31	393.065  Application and eligibility determination.-
32	(5)  Except as otherwise directed by law, beginning July 1,
33	2010, the agency shall assign and provide priority to clients
34	waiting for waiver services in categories 1 and 2 and, beginning
35	July 1, 2012, shall assign and provide priority to clients
36	waiting for waiver services in categories 3, 4, 5, 6, and 7, in
37	the following order:
38	(a)  Category 1, which includes clients deemed to be in
39	crisis as described in rule.
40	(b)  Category 2, which includes children on the wait list
41	who are from the child welfare system with an open case in the
42	Department of Children and Family Services' statewide automated
43	child welfare information system.
44	(c)  Category 3, which includes, but is not required to be
45	limited to, clients:
46	1.  Whose caregiver has a documented condition that is
47	expected to render the caregiver unable to provide care within
48	the next 12 months and for whom a caregiver is required but no
49	alternate caregiver is available;
50	2.  At substantial risk of incarceration or court
51	commitment without supports;
52	3.  Whose documented behaviors or physical needs place them
53	or their caregiver at risk of serious harm and other supports
54	are not currently available to alleviate the situation; or
55	4.  Who are identified as ready for discharge within the
56	next year from a state mental health hospital or skilled nursing
57	facility and who require a caregiver but for whom no caregiver
58	is available.
59	(d)  Category 4, which includes, but is not required to be
60	limited to, clients whose caregivers are 70 years of age or
61	older and for whom a caregiver is required but no alternate
62	caregiver is available.
63	(e)  Category 5, which includes, but is not required to be
64	limited to, clients who are expected to graduate within the next
65	12 months from secondary school and need support to obtain or
66	maintain competitive employment, or to pursue an accredited
67	program of postsecondary education to which they have been
68	accepted.
69	(f)  Category 6, which includes clients 21 years of age or
70	older who do not meet the criteria for category 1, category 2,
71	category 3, category 4, or category 5.
72	(g)  Category 7, which includes clients younger than 21
73	years of age who do not meet the criteria for category 1,
74	category 2, category 3, or category 4.
75
76	Within categories 3, 4, 5, 6, and 7, the agency shall maintain a
77	wait list of clients placed in the order of the date that the
78	client 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
81	amended to read:
82	393.0661  Home and community-based services delivery
83	system; comprehensive redesign.-The Legislature finds that the
84	home and community-based services delivery system for persons
85	with developmental disabilities and the availability of
86	appropriated funds are two of the critical elements in making
87	services available. Therefore, it is the intent of the
88	Legislature that the Agency for Persons with Disabilities shall
89	develop and implement a comprehensive redesign of the system.
90	(1)  The redesign of the home and community-based services
91	system shall include, at a minimum, all actions necessary to
92	achieve an appropriate rate structure, client choice within a
93	specified service package, appropriate assessment strategies, an
94	efficient billing process that contains reconciliation and
95	monitoring components, a redefined role for support coordinators
96	that avoids potential conflicts of interest, and ensures that
97	family/client budgets are linked to levels of need.
98	(a)  The agency shall use either the Department of Children
99	and Family Services' Individual Cost Guidelines or the agency's
100	Questionnaire for Situational Information as an assessment
101	instrument that is reliable and valid. The agency may contract
102	with an external vendor or may use support coordinators to
103	complete client assessments if it develops sufficient safeguards
104	and training to ensure ongoing inter-rater reliability.
105	(3)  The Agency for Health Care Administration, in
106	consultation with the agency, shall seek federal approval and
107	implement a four-tiered waiver system to serve eligible clients
108	through the developmental disabilities and family and supported
109	living waivers. The agency shall assign all clients receiving
110	services through the developmental disabilities waiver to a tier
111	based on the Individual Cost Guidelines or the Questionnaire for
112	Situational Information; a valid assessment instrument, client
113	characteristics, including, but not limited to, age; and other
114	appropriate assessment methods.
115	(a)  Tier one is limited to clients who have service needs
116	that cannot be met in tier two, three, or four for intensive
117	medical or adaptive needs and that are essential for avoiding
118	institutionalization, or who possess behavioral problems that
119	are exceptional in intensity, duration, or frequency and present
120	a substantial risk of harm to themselves or others.
121	(b)  Tier two is limited to clients whose service needs
122	include a licensed residential facility and who are authorized
123	to receive a moderate level of support for standard residential
124	habilitation services or a minimal level of support for behavior
125	focus residential habilitation services, or clients in supported
126	living who receive more than 6 hours a day of in-home support
127	services. Total annual expenditures under tier two may not
128	exceed $55,000 per client each year.
129	(c)  Tier three includes, but is not limited to, clients
130	requiring residential placements, clients in independent or
131	supported living situations, and clients who live in their
132	family home. Total annual expenditures under tier three may not
133	exceed $35,000 per client each year.
134	(d)  Tier four includes individuals who were enrolled in is
135	the family and supported living waiver on July 1, 2007, who
136	shall be assigned to this tier without the assessments required
137	by this section. Tier four also and includes, but is not limited
138	to, clients in independent or supported living situations and
139	clients who live in their family home. Total annual expenditures
140	under tier four may not exceed $14,792 per client each year.
141	(e)  The Agency for Health Care Administration shall also
142	seek federal approval to provide a consumer-directed option for
143	persons with developmental disabilities which corresponds to the
144	funding levels in each of the waiver tiers. The agency shall
145	implement the four-tiered waiver system beginning with tiers
146	one, three, and four and followed by tier two. The agency and
147	the Agency for Health Care Administration may adopt rules
148	necessary to administer this subsection.
149	(f)  The agency shall seek federal waivers and amend
150	contracts as necessary to make changes to services defined in
151	federal waiver programs administered by the agency as follows:
152	1.  Supported living coaching services may not exceed 20
153	hours per month for persons who also receive in-home support
154	services.
155	2.  Limited support coordination services is the only type
156	of support coordination service that may be provided to persons
157	under the age of 18 who live in the family home.
158	3.  Personal care assistance services are limited to 180
159	hours per calendar month and may not include rate modifiers.
160	Additional hours may be authorized for persons who have
161	intensive physical, medical, or adaptive needs if such hours are
162	essential for avoiding institutionalization.
163	4.  Residential habilitation services are limited to 8
164	hours per day. Additional hours may be authorized for persons
165	who have intensive medical or adaptive needs and if such hours
166	are essential for avoiding institutionalization, or for persons
167	who possess behavioral problems that are exceptional in
168	intensity, duration, or frequency and present a substantial risk
169	of harming themselves or others. This restriction shall be in
170	effect until the four-tiered waiver system is fully implemented.
171	5.  Chore services, nonresidential support services, and
172	homemaker services are eliminated. The agency shall expand the
173	definition of in-home support services to allow the service
174	provider to include activities previously provided in these
175	eliminated services.
176	6.  Massage therapy, medication review, behavior assistance
177	services, and psychological assessment services are eliminated.
178	7.  The agency shall conduct supplemental cost plan reviews
179	to verify the medical necessity of authorized services for plans
180	that have increased by more than 8 percent during either of the
181	2 preceding fiscal years.
182	8.  The agency shall implement a consolidated residential
183	habilitation rate structure to increase savings to the state
184	through a more cost-effective payment method and establish
185	uniform rates for intensive behavioral residential habilitation
186	services.
187	9.  Pending federal approval, the agency may extend current
188	support plans for clients receiving services under Medicaid
189	waivers for 1 year beginning July 1, 2007, or from the date
190	approved, whichever is later. Clients who have a substantial
191	change in circumstances which threatens their health and safety
192	may be reassessed during this year in order to determine the
193	necessity for a change in their support plan.
194	10.  The agency shall develop a plan to eliminate
195	redundancies and duplications between in-home support services,
196	companion services, personal care services, and supported living
197	coaching by limiting or consolidating such services.
198	11.  The agency shall develop a plan to reduce the
199	intensity and frequency of supported employment services to
200	clients in stable employment situations who have a documented
201	history of at least 3 years' employment with the same company or
202	in the same industry.
203	(4)  Effective July 1, 2010, the geographic differential
204	for Miami-Dade, Broward, and Palm Beach Counties for residential
205	habilitation services shall be 4.5 7.5 percent.
206	(5)(a)  Effective July 1, 2010, the geographic differential
207	for Monroe County for residential habilitation services shall be
208	15 20 percent.
209	(b)  Effective July 1, 2011, the geographic differential
210	for Monroe County for residential habilitation services shall be
211	10 percent.
212	Section 3.  Section 393.0662, Florida Statutes, is created
213	to read:
214	393.0662  Individual budgets for delivery of home and
215	community-based services; iBudget system established.-The
216	Legislature finds that improved financial management of the
217	existing home and community-based Medicaid waiver program is
218	necessary to avoid deficits that impede the provision of
219	services to individuals who are on the waiting list for
220	enrollment in the program. The Legislature further finds that
221	clients and their families should have greater flexibility to
222	choose the services that best allow them to live in their
223	community within the limits of an established budget. Therefore,
224	the Legislature intends that the agency, in consultation with
225	the Agency for Health Care Administration, develop and implement
226	a comprehensive redesign of the service delivery system using
227	individual budgets as the basis for allocating the funds
228	appropriated for the home and community-based services Medicaid
229	waiver program among eligible enrolled clients. The service
230	delivery system that uses individual budgets shall be called the
231	iBudget system.
232	(1)  The agency shall establish an individual budget,
233	referred to as an iBudget, for each individual served by the
234	home and community-based services Medicaid waiver program. The
235	funds appropriated to the agency shall be allocated through the
236	iBudget system to eligible, Medicaid-enrolled clients. The
237	iBudget system shall be designed to provide for: enhanced client
238	choice within a specified service package; appropriate
239	assessment strategies; an efficient consumer budgeting and
240	billing process that includes reconciliation and monitoring
241	components; a redefined role for support coordinators that
242	avoids potential conflicts of interest; a flexible and
243	streamlined service review process; and a methodology and
244	process that ensures the equitable allocation of available funds
245	to each client based on the client's level of need, as
246	determined by the variables in the allocation algorithm.
247	(a)  In developing each client's iBudget, the agency shall
248	use an allocation algorithm and methodology. The algorithm shall
249	use variables that have been determined by the agency to have a
250	statistically validated relationship to the client's level of
251	need for services provided through the home and community-based
252	services Medicaid waiver program. The algorithm and methodology
253	may consider individual characteristics, including, but not
254	limited to, a client's age and living situation, information
255	from a formal assessment instrument that the agency determines
256	is valid and reliable, and information from other assessment
257	processes.
258	(b)  The allocation methodology shall provide the algorithm
259	that determines the amount of funds allocated to a client's
260	iBudget. The agency may approve an increase in the amount of
261	funds allocated, as determined by the algorithm, based on the
262	client having:
263	1.  An extraordinary need that would place the health and
264	safety of the client, the client's caregiver, or the public in
265	immediate, serious jeopardy unless the increase is approved. An
266	extraordinary need may include, but is not limited to:
267	a.  A documented history of significant, potentially life-
268	threatening behaviors, such as recent attempts at suicide,
269	arson, nonconsensual sexual behavior, or self-injurious behavior
270	requiring medical attention;
271	b.  A complex medical condition that requires active
272	intervention by a licensed nurse on an ongoing basis that cannot
273	be taught or delegated to a nonlicensed person;
274	c.  A chronic co-morbid condition. As used in this
275	subparagraph, the term "co-morbid condition" means a medical
276	condition existing simultaneously but independently with another
277	medical condition in a patient; or
278	d.  A need for total physical assistance with activities
279	such as eating, bathing, toileting, grooming, and personal
280	hygiene.
281
282	However, the presence of an extraordinary need alone does not
283	warrant an increase in the amount of funds allocated to a
284	client's iBudget as determined by the algorithm.
285	2.  A significant need for one-time or temporary support or
286	services that, if not provided, would place the health and
287	safety of the client, the client's caregiver, or the public in
288	serious jeopardy, unless the increase, as determined by the
289	total of the algorithm and any adjustments based on
290	subparagraphs 1. and 3., is approved. A significant need may
291	include, but is not limited to, the provision of environmental
292	modifications, durable medical equipment, services to address
293	the temporary loss of support from a caregiver, or special
294	services or treatment for a serious temporary condition when the
295	service or treatment is expected to ameliorate the underlying
296	condition. As used in this subparagraph, the term "temporary"
297	means a period of fewer than 12 continuous months.
298	3.  A significant increase in the need for services after
299	the beginning of the service plan year that would place the
300	health and safety of the client, the client's caregiver, or the
301	public in serious jeopardy because of substantial changes in the
302	client's circumstances, including, but not limited to, permanent
303	or long-term loss or incapacity of a caregiver, loss of services
304	authorized under the state Medicaid plan due to a change in age,
305	or a significant change in medical or functional status which
306	requires the provision of additional services on a permanent or
307	long-term basis that cannot be accommodated within the client's
308	current iBudget. As used in this subparagraph, the term "long-
309	term" means a period of 12 or more continuous months.
310
311	The agency shall reserve portions of the appropriation for the
312	home and community-based services Medicaid waiver program for
313	adjustments required pursuant to this paragraph and may use the
314	services of an independent actuary in determining the amount of
315	the portions to be reserved.
316	(c)  A client's iBudget shall be the total of the amount
317	determined by the algorithm and any additional funding provided
318	pursuant to paragraph (a). A client's annual expenditures for
319	home and community-based services Medicaid waiver services may
320	not exceed the limits of his or her iBudget. The total of a
321	client's projected annual iBudget expenditures may not exceed
322	the agency's appropriation for waiver services.
323	(2)  The Agency for Health Care Administration, in
324	consultation with the agency, shall seek federal approval to
325	amend current waivers, request a new waiver, and amend contracts
326	as necessary to implement the iBudget system to serve eligible,
327	enrolled clients through the home and community-based services
328	Medicaid waiver program and the Consumer-Directed Care Plus
329	Program.
330	(3)  The agency shall transition all eligible, enrolled
331	clients to the iBudget system. The agency may gradually phase in
332	the iBudget system.
333	(a)  While the agency phases in the iBudget system, the
334	agency may continue to serve eligible, enrolled clients under
335	the four-tiered waiver system established under s. 393.065 while
336	those clients await transitioning to the iBudget system.
337	(b)  The agency shall design the phase-in process to ensure
338	that a client does not experience more than one-half of any
339	expected overall increase or decrease to his or her existing
340	annualized cost plan during the first year that the client is
341	provided an iBudget due solely to the transition to the iBudget
342	system.
343	(4)  A client must use all available services authorized
344	under the state Medicaid plan, school-based services, private
345	insurance and other benefits, and any other resources that may
346	be available to the client before using funds from his or her
347	iBudget to pay for support and services.
348	(5)  Rates for any or all services established under rules
349	of the Agency for Health Care Administration shall be designated
350	as the maximum rather than a fixed amount for individuals who
351	receive an iBudget, except for services specifically identified
352	in those rules that the agency determines are not appropriate
353	for negotiation, which may include, but are not limited to,
354	residential habilitation services.
355	(6)  The agency shall ensure that clients and caregivers
356	have access to training and education to inform them about the
357	iBudget system and enhance their ability for self-direction.
358	Such training shall be offered in a variety of formats and at a
359	minimum shall address the policies and processes of the iBudget
360	system; the roles and responsibilities of consumers, caregivers,
361	waiver support coordinators, providers, and the agency;
362	information available to help the client make decisions
363	regarding the iBudget system; and examples of support and
364	resources available in the community.
365	(7)  The agency shall collect data to evaluate the
366	implementation and outcomes of the iBudget system.
367	(8)  The agency and the Agency for Health Care
368	Administration may adopt rules specifying the allocation
369	algorithm and methodology; criteria and processes for clients to
370	access reserved funds for extraordinary needs, temporarily or
371	permanently changed needs, and one-time needs; and processes and
372	requirements for selection and review of services, development
373	of support and cost plans, and management of the iBudget system
374	as needed to administer this section.
375	Section 4.  Subsection (1) of section 393.125, Florida
376	Statutes, is amended to read:
377	393.125  Hearing rights.-
378	(1)  REVIEW OF AGENCY DECISIONS.-
379	(a)  For Medicaid programs administered by the agency, any
380	developmental services applicant or client, or his or her
381	parent, guardian advocate, or authorized representative, may
382	request a hearing in accordance with federal law and rules
383	applicable to Medicaid cases and has the right to request an
384	administrative hearing pursuant to ss. 120.569 and 120.57. These
385	hearings shall be provided by the Department of Children and
386	Family Services pursuant to s. 409.285 and shall follow
387	procedures consistent with federal law and rules applicable to
388	Medicaid cases.
389	(b)(a)  Any other developmental services applicant or
390	client, or his or her parent, guardian, guardian advocate, or
391	authorized representative, who has any substantial interest
392	determined by the agency, has the right to request an
393	administrative hearing pursuant to ss. 120.569 and 120.57, which
394	shall be conducted pursuant to s. 120.57(1), (2), or (3).
395	(c)(b)  Notice of the right to an administrative hearing
396	shall be given, both verbally and in writing, to the applicant
397	or client, and his or her parent, guardian, guardian advocate,
398	or authorized representative, at the same time that the agency
399	gives the applicant or client notice of the agency's action. The
400	notice shall be given, both verbally and in writing, in the
401	language of the client or applicant and in English.
402	(d)(c)  A request for a hearing under this section shall be
403	made to the agency, in writing, within 30 days after of the
404	applicant'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.