Florida Senate - 2020                                      SB 82
       By Senator Bean
       4-01661A-20                                             202082__
    1                        A bill to be entitled                      
    2         An act relating to individuals with disabilities;
    3         amending s. 393.063, F.S.; defining the term
    4         “significant additional need”; revising the definition
    5         of the term “support coordinator”; amending s.
    6         393.066, F.S.; requiring persons and entities under
    7         contract with the Agency for Persons with Disabilities
    8         to use the agency data management systems to bill for
    9         services; repealing s. 393.0661, F.S., relating to the
   10         home and community-based services delivery system;
   11         amending s. 393.0662, F.S.; revising criteria used by
   12         the agency to develop a client’s iBudget; revising
   13         criteria used by the agency to authorize additional
   14         funding for certain clients; requiring the agency to
   15         certify and document the use of certain services
   16         before approving the expenditure of certain funds;
   17         requiring the Agency for Health Care Administration to
   18         seek federal approval to provide consumer-directed
   19         options; authorizing the Agency for Persons with
   20         Disabilities and the Agency for Health Care
   21         Administration to adopt rules; requiring the Agency
   22         for Health Care Administration to seek federal waivers
   23         and amend contracts under certain conditions;
   24         requiring the Agency for Persons with Disabilities to
   25         collect premiums or cost sharing; providing
   26         construction; providing for the reimbursement of
   27         certain providers of services; requiring the Agency
   28         for Persons with Disabilities to submit quarterly
   29         status reports to the Governor, the chair of the
   30         Senate Appropriations Committee, and the chair of the
   31         House Appropriations Committee; requiring the Agency
   32         for Persons with Disabilities, in consultation with
   33         the Agency for Health Care Administration, to submit a
   34         certain plan to the Governor, the chair of the Senate
   35         Appropriations Committee, and the chair of the House
   36         Appropriations Committee under certain conditions;
   37         requiring the Agency for Persons with Disabilities, in
   38         consultation with the Agency for Health Care
   39         Administration, to provide quarterly reconciliation
   40         reports to the Governor and the Legislature within a
   41         specified timeframe; revising rulemaking authority of
   42         the Agency for Persons with Disabilities and the
   43         Agency for Health Care Administration; creating s.
   44         393.0663, F.S.; requiring the Agency for Persons with
   45         Disabilities to competitively procure qualified
   46         organizations to provide support coordination
   47         services; requiring such procurement to be initiated
   48         on a specified date; providing requirements for
   49         contracts awarded by the agency; amending s. 409.906,
   50         F.S.; requiring the Agency for Health Care
   51         Administration to contract with an external vendor for
   52         certain medical necessity determinations; requiring
   53         the Agency for Persons with Disabilities to seek
   54         federal approval to implement certain payment rates;
   55         amending ss. 409.968 and 1002.385, F.S.; conforming
   56         cross-references; providing an effective date.
   58  Be It Enacted by the Legislature of the State of Florida:
   60         Section 1. Present subsections (39) through (45) of section
   61  393.063, Florida Statutes, are redesignated as subsections (40)
   62  through (46), respectively, a new subsection (39) is added to
   63  that section, and present subsection (41) of that section is
   64  amended, to read:
   65         393.063 Definitions.—For the purposes of this chapter, the
   66  term:
   67         (39) “Significant additional need” means a medically
   68  necessary need for a service increase arising after the
   69  beginning of the service plan year which would place the health
   70  and safety of the client, the client’s caregiver, or the public
   71  in serious jeopardy.
   72         (42)(41) “Support coordinator” means an employee of a
   73  qualified organization pursuant to s. 393.0663 a person who is
   74  designated by the agency to assist individuals and families in
   75  identifying their capacities, needs, and resources, as well as
   76  finding and gaining access to necessary supports and services;
   77  coordinating the delivery of supports and services; advocating
   78  on behalf of the individual and family; maintaining relevant
   79  records; and monitoring and evaluating the delivery of supports
   80  and services to determine the extent to which they meet the
   81  needs and expectations identified by the individual, family, and
   82  others who participated in the development of the support plan.
   83         Section 2. Subsection (2) of section 393.066, Florida
   84  Statutes, is amended to read:
   85         393.066 Community services and treatment.—
   86         (2) Necessary services shall be purchased, rather than
   87  provided directly by the agency, when the purchase of services
   88  is more cost-efficient than providing them directly. All
   89  purchased services must be approved by the agency. As a
   90  condition of payment, persons or entities under contract with
   91  the agency to provide services shall use agency data management
   92  systems to document service provision to clients before billing
   93  and must use the agency data management systems to bill for
   94  services. Contracted persons and entities shall meet the minimum
   95  hardware and software technical requirements established by the
   96  agency for the use of such systems. Such persons or entities
   97  shall also meet any requirements established by the agency for
   98  training and professional development of staff providing direct
   99  services to clients.
  100         Section 3. Section 393.0661, Florida Statutes, is repealed.
  101         Section 4. Section 393.0662, Florida Statutes, is amended
  102  to read:
  103         393.0662 Individual budgets for delivery of home and
  104  community-based services; iBudget system established.—The
  105  Legislature finds that improved financial management of the
  106  existing home and community-based Medicaid waiver program is
  107  necessary to avoid deficits that impede the provision of
  108  services to individuals who are on the waiting list for
  109  enrollment in the program. The Legislature further finds that
  110  clients and their families should have greater flexibility to
  111  choose the services that best allow them to live in their
  112  community within the limits of an established budget. Therefore,
  113  the Legislature intends that the agency, in consultation with
  114  the Agency for Health Care Administration, shall manage the
  115  service delivery system using individual budgets as the basis
  116  for allocating the funds appropriated for the home and
  117  community-based services Medicaid waiver program among eligible
  118  enrolled clients. The service delivery system that uses
  119  individual budgets shall be called the iBudget system.
  120         (1) The agency shall administer an individual budget,
  121  referred to as an iBudget, for each individual served by the
  122  home and community-based services Medicaid waiver program. The
  123  funds appropriated to the agency shall be allocated through the
  124  iBudget system to eligible, Medicaid-enrolled clients. For the
  125  iBudget system, eligible clients shall include individuals with
  126  a developmental disability as defined in s. 393.063. The iBudget
  127  system shall provide for: enhanced client choice within a
  128  specified service package; appropriate assessment strategies; an
  129  efficient consumer budgeting and billing process that includes
  130  reconciliation and monitoring components; a role for support
  131  coordinators that avoids potential conflicts of interest; a
  132  flexible and streamlined service review process; and the
  133  equitable allocation of available funds based on the client’s
  134  level of need, as determined by the allocation methodology.
  135         (a) In developing each client’s iBudget, the agency shall
  136  use the allocation methodology as defined in s. 393.063(4), in
  137  conjunction with an assessment instrument that the agency deems
  138  to be reliable and valid, including, but not limited to, the
  139  agency’s Questionnaire for Situational Information. The
  140  allocation methodology shall determine the amount of funds
  141  allocated to a client’s iBudget.
  142         (b) The agency may authorize additional funding based on a
  143  client having one or more significant additional needs of the
  144  following needs that cannot be accommodated within the funding
  145  determined by the algorithm and having no other resources,
  146  supports, or services available to meet the needs. Such
  147  additional funding may be provided only after the determination
  148  of a client’s initial allocation amount and after the agency has
  149  certified and documented the use of all available resources
  150  under the Medicaid state plan as described in subsection (2).
  151  need:
  152         1. An extraordinary need that would place the health and
  153  safety of the client, the client’s caregiver, or the public in
  154  immediate, serious jeopardy unless the increase is approved.
  155  However, the presence of an extraordinary need in and of itself
  156  does not warrant authorized funding by the agency. An
  157  extraordinary need may include, but is not limited to:
  158         a. A documented history of significant, potentially life
  159  threatening behaviors, such as recent attempts at suicide,
  160  arson, nonconsensual sexual behavior, or self-injurious behavior
  161  requiring medical attention;
  162         b. A complex medical condition that requires active
  163  intervention by a licensed nurse on an ongoing basis that cannot
  164  be taught or delegated to a nonlicensed person;
  165         c. A chronic comorbid condition. As used in this
  166  subparagraph, the term “comorbid condition” means a medical
  167  condition existing simultaneously but independently with another
  168  medical condition in a patient; or
  169         d. A need for total physical assistance with activities
  170  such as eating, bathing, toileting, grooming, and personal
  171  hygiene.
  172         2. A significant need for one-time or temporary support or
  173  services that, if not provided, would place the health and
  174  safety of the client, the client’s caregiver, or the public in
  175  serious jeopardy. A significant need may include, but is not
  176  limited to, the provision of environmental modifications,
  177  durable medical equipment, services to address the temporary
  178  loss of support from a caregiver, or special services or
  179  treatment for a serious temporary condition when the service or
  180  treatment is expected to ameliorate the underlying condition. As
  181  used in this subparagraph, the term “temporary” means a period
  182  of fewer than 12 continuous months. However, the presence of
  183  such significant need for one-time or temporary supports or
  184  services in and of itself does not warrant authorized funding by
  185  the agency.
  186         3. A significant increase in the need for services after
  187  the beginning of the service plan year that would place the
  188  health and safety of the client, the client’s caregiver, or the
  189  public in serious jeopardy because of substantial changes in the
  190  client’s circumstances, including, but not limited to, permanent
  191  or long-term loss or incapacity of a caregiver, loss of services
  192  authorized under the state Medicaid plan due to a change in age,
  193  or a significant change in medical or functional status which
  194  requires the provision of additional services on a permanent or
  195  long-term basis that cannot be accommodated within the client’s
  196  current iBudget. As used in this subparagraph, the term “long
  197  term” means a period of 12 or more continuous months. However,
  198  such significant increase in need for services of a permanent or
  199  long-term nature in and of itself does not warrant authorized
  200  funding by the agency.
  201         4. A significant need for transportation services to a
  202  waiver-funded adult day training program or to waiver-funded
  203  employment services when such need cannot be accommodated within
  204  a client’s iBudget as determined by the algorithm without
  205  affecting the health and safety of the client, if public
  206  transportation is not an option due to the unique needs of the
  207  client or other transportation resources are not reasonably
  208  available.
  210  The agency shall reserve portions of the appropriation for the
  211  home and community-based services Medicaid waiver program for
  212  adjustments required pursuant to this paragraph and may use the
  213  services of an independent actuary in determining the amount to
  214  be reserved.
  215         (c) A client’s annual expenditures for home and community
  216  based Medicaid waiver services may not exceed the limits of his
  217  or her iBudget. The total of all clients’ projected annual
  218  iBudget expenditures may not exceed the agency’s appropriation
  219  for waiver services.
  220         (2) The Agency for Health Care Administration, in
  221  consultation with the agency, shall seek federal approval to
  222  amend current waivers, request a new waiver, and amend contracts
  223  as necessary to manage the iBudget system, improve services for
  224  eligible and enrolled clients, and improve the delivery of
  225  services through the home and community-based services Medicaid
  226  waiver program and the Consumer-Directed Care Plus Program,
  227  including, but not limited to, enrollees with a dual diagnosis
  228  of a developmental disability and a mental health disorder.
  229         (3) The agency must certify and document within each
  230  client’s cost plan that the a client has used must use all
  231  available services authorized under the state Medicaid plan,
  232  school-based services, private insurance and other benefits, and
  233  any other resources that may be available to the client before
  234  using funds from his or her iBudget to pay for support, and
  235  services, and any significant additional needs as determined by
  236  a qualified organization contracted pursuant to s.
  237  409.906(13)(c).
  238         (4) Rates for any or all services established under rules
  239  of the Agency for Health Care Administration must be designated
  240  as the maximum rather than a fixed amount for individuals who
  241  receive an iBudget, except for services specifically identified
  242  in those rules that the agency determines are not appropriate
  243  for negotiation, which may include, but are not limited to,
  244  residential habilitation services.
  245         (5) The agency shall ensure that clients and caregivers
  246  have access to training and education that inform them about the
  247  iBudget system and enhance their ability for self-direction.
  248  Such training and education must be offered in a variety of
  249  formats and, at a minimum, must address the policies and
  250  processes of the iBudget system and the roles and
  251  responsibilities of consumers, caregivers, waiver support
  252  coordinators, providers, and the agency, and must provide
  253  information to help the client make decisions regarding the
  254  iBudget system and examples of support and resources available
  255  in the community.
  256         (6) The agency shall collect data to evaluate the
  257  implementation and outcomes of the iBudget system.
  258         (7) The Agency for Health Care Administration shall seek
  259  federal approval to provide a consumer-directed option for
  260  persons with developmental disabilities. The agency and the
  261  Agency for Health Care Administration may adopt rules necessary
  262  to administer this subsection.
  263         (8)The Agency for Health Care Administration shall seek
  264  federal waivers and amend contracts as necessary to make changes
  265  to services defined in federal waiver programs as follows:
  266         (a) Supported living coaching services may not exceed 20
  267  hours per month for persons who also receive in-home support
  268  services.
  269         (b) Limited support coordination services are the only type
  270  of support coordination services which may be provided to
  271  persons under the age of 18 who live in the family home.
  272         (c) Personal care assistance services are limited to 180
  273  hours per calendar month and may not include rate modifiers.
  274  Additional hours may be authorized for persons who have
  275  intensive physical, medical, or adaptive needs if such hours are
  276  essential for avoiding institutionalization.
  277         (d) Residential habilitation services are limited to 8
  278  hours per day. Additional hours may be authorized for persons
  279  who have intensive medical or adaptive needs and if such hours
  280  are essential for avoiding institutionalization, or for persons
  281  who possess behavioral problems that are exceptional in
  282  intensity, duration, or frequency and present a substantial risk
  283  of harming themselves or others.
  284         (e) The agency shall conduct supplemental cost plan reviews
  285  to verify the medical necessity of authorized services for plans
  286  that have increased by more than 8 percent during either of the
  287  2 preceding fiscal years.
  288         (f) The agency shall implement a consolidated residential
  289  habilitation rate structure to increase savings to the state
  290  through a more cost-effective payment method and establish
  291  uniform rates for intensive behavioral residential habilitation
  292  services.
  293         (g) The geographic differential for Miami-Dade, Broward,
  294  and Palm Beach Counties for residential habilitation services
  295  must be 7.5 percent.
  296         (h) The geographic differential for Monroe County for
  297  residential habilitation services must be 20 percent.
  298         (9) The agency shall collect premiums or cost sharing
  299  pursuant to s. 409.906(13)(c).
  300         (10) This section or any related rule does not prevent or
  301  limit the Agency for Health Care Administration, in consultation
  302  with the agency, from adjusting fees, reimbursement rates,
  303  lengths of stay, number of visits, or number of services, or
  304  from limiting enrollment or making any other adjustment
  305  necessary to comply with the availability of moneys and any
  306  limitations or directions provided in the General Appropriations
  307  Act.
  308         (11)A provider of services rendered to persons with
  309  developmental disabilities pursuant to a federally approved
  310  waiver shall be reimbursed according to a rate methodology based
  311  upon an analysis of the expenditure history and prospective
  312  costs of providers participating in the waiver program, or under
  313  any other methodology developed by the Agency for Health Care
  314  Administration, in consultation with the agency, and approved by
  315  the Federal Government in accordance with the waiver.
  316         (12) The agency shall submit quarterly status reports to
  317  the Executive Office of the Governor, the chair of the Senate
  318  Appropriations Committee or its successor, and the chair of the
  319  House Appropriations Committee or its successor containing all
  320  of the following information:
  321         (a)The financial status of home and community-based
  322  services, including the number of enrolled individuals who are
  323  receiving services through one or more programs.
  324         (b)The number of individuals who have requested services
  325  who are not enrolled but who are receiving services through one
  326  or more programs, with a description indicating the programs
  327  from which the individual is receiving services.
  328         (c)The number of individuals who have refused an offer of
  329  services but who choose to remain on the list of individuals
  330  waiting for services.
  331         (d)The number of individuals who have requested services
  332  but who are receiving no services.
  333         (e)A frequency distribution indicating the length of time
  334  individuals have been waiting for services.
  335         (f)Information concerning the actual and projected costs
  336  compared to the amount of the appropriation available to the
  337  program and any projected surpluses or deficits.
  338         (13)If at any time an analysis by the agency, in
  339  consultation with the Agency for Health Care Administration,
  340  indicates that the cost of services is expected to exceed the
  341  amount appropriated, the agency shall submit a plan in
  342  accordance with subsection (10) to the Executive Office of the
  343  Governor, the chair of the Senate Appropriations Committee or
  344  its successor, and the chair of the House Appropriations
  345  Committee or its successor to remain within the amount
  346  appropriated. The agency shall work with the Agency for Health
  347  Care Administration to implement the plan so as to remain within
  348  the appropriation.
  349         (14) The agency, in consultation with the Agency for Health
  350  Care Administration, shall provide a quarterly reconciliation
  351  report of all home and community-based services waiver
  352  expenditures from the Agency for Health Care Administration’s
  353  claims management system with service utilization from the
  354  Agency for Persons with Disabilities Allocation, Budget, and
  355  Contract Control system. The reconciliation report shall be
  356  submitted to the Governor, the President of the Senate, and the
  357  Speaker of the House of Representatives no later than 30 days
  358  after the close of each quarter.
  359         (15)(7) The agency and the Agency for Health Care
  360  Administration may adopt rules specifying the allocation
  361  algorithm and methodology; criteria and processes for clients to
  362  access reserved funds for significant additional needs
  363  extraordinary needs, temporarily or permanently changed needs,
  364  and one-time needs; and processes and requirements for selection
  365  and review of services, development of support and cost plans,
  366  and management of the iBudget system as needed to administer
  367  this section.
  368         Section 5. Section 393.0663, Florida Statutes, is created
  369  to read:
  370         393.0663 Waiver support coordination services.—The agency
  371  shall competitively procure two or more qualified organizations
  372  to provide support coordination services. In awarding a contract
  373  to a qualified organization, the agency shall take into account
  374  price, quality, and accessibility to these services. The agency
  375  shall initiate procurement on October 1, 2020.
  376         (1) The contract must include provisions requiring
  377  compliance with agency cost-containment initiatives.
  378         (2) The contract must require support coordinators to
  379  ensure client budgets are linked to levels of need.
  380         (3) The contract must require support coordinators to avoid
  381  potential conflicts of interest.
  382         (4) The contract must require the organization to perform
  383  all duties and meet all standards related to support
  384  coordination as provided in the Developmental Disabilities
  385  Waiver Services Coverage and Limitations Handbook.
  386         (5) The contract shall be 3 years in duration. Following
  387  the initial 3-year period, the contract may be renewed annually
  388  for 3 consecutive years and may not exceed 1 year in duration.
  389         (6) The contract may provide for support coordination
  390  services statewide or by agency region, at the discretion of the
  391  agency.
  392         Section 6. Present paragraphs (c) and (d) of subsection
  393  (13) of section 409.906, Florida Statutes, are redesignated as
  394  paragraphs (d) and (e), respectively, a new paragraph (c) is
  395  added to that subsection, and subsection (15) of that section is
  396  amended, to read:
  397         409.906 Optional Medicaid services.—Subject to specific
  398  appropriations, the agency may make payments for services which
  399  are optional to the state under Title XIX of the Social Security
  400  Act and are furnished by Medicaid providers to recipients who
  401  are determined to be eligible on the dates on which the services
  402  were provided. Any optional service that is provided shall be
  403  provided only when medically necessary and in accordance with
  404  state and federal law. Optional services rendered by providers
  405  in mobile units to Medicaid recipients may be restricted or
  406  prohibited by the agency. Nothing in this section shall be
  407  construed to prevent or limit the agency from adjusting fees,
  408  reimbursement rates, lengths of stay, number of visits, or
  409  number of services, or making any other adjustments necessary to
  410  comply with the availability of moneys and any limitations or
  411  directions provided for in the General Appropriations Act or
  412  chapter 216. If necessary to safeguard the state’s systems of
  413  providing services to elderly and disabled persons and subject
  414  to the notice and review provisions of s. 216.177, the Governor
  415  may direct the Agency for Health Care Administration to amend
  416  the Medicaid state plan to delete the optional Medicaid service
  417  known as “Intermediate Care Facilities for the Developmentally
  418  Disabled.” Optional services may include:
  420         (c) The agency shall competitively procure a qualified
  421  organization to perform medical necessity determinations of
  422  significant additional needs requests, as defined in s. 393.063.
  424  DISABLED SERVICES.—The agency may pay for health-related care
  425  and services provided on a 24-hour-a-day basis by a facility
  426  licensed and certified as a Medicaid Intermediate Care Facility
  427  for the Developmentally Disabled, for a recipient who needs such
  428  care because of a developmental disability. Payment shall not
  429  include bed-hold days except in facilities with occupancy rates
  430  of 95 percent or greater. The agency is authorized to seek any
  431  federal waiver approvals to implement this policy. The agency
  432  shall seek federal approval to implement a payment rate for
  433  Medicaid intermediate care facilities serving individuals with
  434  developmental disabilities, severe maladaptive behaviors, severe
  435  maladaptive behaviors and co-occurring complex medical
  436  conditions, or a dual diagnosis of developmental disability and
  437  mental illness.
  438         Section 7. Paragraph (a) of subsection (4) of section
  439  409.968, Florida Statutes, is amended to read:
  440         409.968 Managed care plan payments.—
  441         (4)(a) Subject to a specific appropriation and federal
  442  approval under s. 409.906(13)(e) s. 409.906(13)(d), the agency
  443  shall establish a payment methodology to fund managed care plans
  444  for flexible services for persons with severe mental illness and
  445  substance use disorders, including, but not limited to,
  446  temporary housing assistance. A managed care plan eligible for
  447  these payments must do all of the following:
  448         1. Participate as a specialty plan for severe mental
  449  illness or substance use disorders or participate in counties
  450  designated by the General Appropriations Act;
  451         2. Include providers of behavioral health services pursuant
  452  to chapters 394 and 397 in the managed care plan’s provider
  453  network; and
  454         3. Document a capability to provide housing assistance
  455  through agreements with housing providers, relationships with
  456  local housing coalitions, and other appropriate arrangements.
  457         Section 8. Paragraph (d) of subsection (2) of section
  458  1002.385, Florida Statutes, is amended to read:
  459         1002.385 The Gardiner Scholarship.—
  460         (2) DEFINITIONS.—As used in this section, the term:
  461         (d) “Disability” means, for a 3- or 4-year-old child or for
  462  a student in kindergarten to grade 12, autism spectrum disorder,
  463  as defined in the Diagnostic and Statistical Manual of Mental
  464  Disorders, Fifth Edition, published by the American Psychiatric
  465  Association; cerebral palsy, as defined in s. 393.063(6); Down
  466  syndrome, as defined in s. 393.063(15); an intellectual
  467  disability, as defined in s. 393.063(24); Phelan-McDermid
  468  syndrome, as defined in s. 393.063(28); Prader-Willi syndrome,
  469  as defined in s. 393.063(29); spina bifida, as defined in s.
  470  393.063(41) s. 393.063(40); being a high-risk child, as defined
  471  in s. 393.063(23)(a); muscular dystrophy; Williams syndrome;
  472  rare diseases which affect patient populations of fewer than
  473  200,000 individuals in the United States, as defined by the
  474  National Organization for Rare Disorders; anaphylaxis; deaf;
  475  visually impaired; traumatic brain injured; hospital or
  476  homebound; or identification as dual sensory impaired, as
  477  defined by rules of the State Board of Education and evidenced
  478  by reports from local school districts. The term “hospital or
  479  homebound” includes a student who has a medically diagnosed
  480  physical or psychiatric condition or illness, as defined by the
  481  state board in rule, and who is confined to the home or hospital
  482  for more than 6 months.
  483         Section 9. This act shall take effect July 1, 2020.