This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h0893.CFS
DATE: 1/24/2022
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: HB 893 Residential Treatment Programs
SPONSOR(S): Melo
TIED BILLS: IDEN./SIM. BILLS: SB 1120
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Children, Families & Seniors Subcommittee Woodruff Brazzell
2) Health Care Appropriations Subcommittee
3) Health & Human Services Committee
SUMMARY ANALYSIS
When children cannot safely remain at home with parents, Florida’s child welfare system finds safe out-of-
home placements for children. After a placement assessment to determine the most appropriate out-of-home
placement, a child may be placed with a relative, fictive kin, licensed foster parent, in a group home or a
residential setting.
The Family First Prevention Services Act (FFPSA) was passed into law as part of the Bipartisan Budget Act on
February 9, 2018. The FFPSA reformed the federal child welfare funding streams. In part, the FPPSA limits
federal funding for placements in group homes. Specifically, federal reimbursement is only available for the first
14 days in group care unless the child is in a specified setting. One such setting is a Qualified Residential
Treatment Program (QRTP), which provides trauma-informed treatment to children with serious emotional or
behavioral disorders or disturbances in a residential setting.
In Florida, Residential Treatment Centers (RTC’s) include Specialized Therapeutic Group Homes (STGH),
Psychiatric Residential Treatment Facilities (PRTF), and the new federally defined QRTP (licensed as a
STGH). Section 39.407(6), F.S., authorizes the Department of Children and Families (DCF) to place a child in
its custody in an RTC or a hospital for residential mental health treatment if the DCF believes the child is
emotionally disturbed and needs residential treatment. Before the child is admitted to an RTC, he or she must
be assessed for suitability for residential treatment by a qualified evaluator (QE) who must be a psychiatrist or
a psychologist licensed in Florida who has at least three years of experience in the diagnosis and treatment of
serious emotional disturbances in children and adolescents. Further, the QE cannot have any actual or
perceived conflict of interest with any inpatient facility or residential treatment center program.
HB 893 makes changes to s. 39.407, F.S., to align with federal requirements, including requiring:
Requiring a QE for a STGH and QRTP to be a licensed clinician with at least two years of experience in
the diagnosis and treatment of serious emotional disturbances in children and adolescents, as opposed
to stricter QE requirements for placement in a SIPP.
Requiring DCF to appoint the QE instead of the Agency for Health Care Administration (AHCA).
Removing AHCA’s rulemaking authority related to the QE network.
Requiring DCF to provide the guardian ad litem and the court a copy of the assessment within five days
after receipt of an assessment.
Increasing the number of beds in a STGH placement from 14 to 16 unrelated residents.
The bill does not have a fiscal impact on state or local governments.
The bill takes effect upon becoming a law.
STORAGE NAME: h0893.CFS PAGE: 2
DATE: 1/24/2022
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Title IV-E Funding for Child Welfare
While states bear primary responsibility for child welfare, Congress appropriates funds to states through
a variety of funding streams for services to children who have suffered maltreatment. One of these
funding streams is established in Title IV-E of the Social Security Act. Title IV-E provides federal
reimbursement to states for a portion of the cost of foster care, adoption assistance, and (in states
electing to provide this kind of support) kinship guardianship assistance on behalf of each child who
meets federal eligibility criteria.
Family First Prevention Services Act
The Family First Prevention Services Act (FFPSA) was passed into law as part of the Bipartisan Budget
Act on February 9, 2018.
1
The FFPSA reformed the federal child welfare funding streams. Unlike the
previous Title IV-E provisions which primarily funded out-of-home care for families with very low
incomes, the FFPSA gives states the ability to earn federal Title IV-E matching funds in support of
certain prevention services provided on a time-limited basis that avoid an out-of-home placement for
children without regard to family income. States can now receive 50% reimbursement for evidence-
based prevention services for children and their families, including mental health, substance abuse,
family counseling, and parent skills training.
In order to pay for the increased funding for prevention services, federal funding is limited for children
placed in group care. Specifically, Title IV-E reimbursement is only available for the first 14 days unless
a child is an FFPSA approved placement, and FFPSA approved group care placements are limited to
specialty homes. FFPSA approved placements include:
Relative/non-relative caregivers.
Licensed foster care placements.
Specialized programs, including at-risk human trafficking homes, safe homes, and maternity
homes.
Supervised independent living for youth over 18.
A new federally defined Qualified Residential Treatment Program (QRTP).
Provisions related to FFPSA took effect in Florida on October 1, 2021. Therefore, the state can no
longer receive federal reimbursement for a child in a non-FFPSA approved placement after 14 days.
Department of Children and Families
The Department of Children and Families (DCF) mission is to work in partnership with local
communities to protect the vulnerable, promote strong and economically self-sufficient families, and
advance personal and family recovery and resiliency.
2
The DCF must develop a strategic plan to fulfill
its mission and establish measurable goals, objectives, performance standards, and quality assurance
requirements to ensure the department is accountable to taxpayers.
3
The DCF must also deliver services by contract through private providers to the extent allowed by law
and funding.
4
These private providers include community-based care lead agencies (CBC’s) delivering
child welfare services.
1
H.R. 1862 of 2018. P.L. 115-123.
2
S. 20.19(1), F.S.
3
Id.
4
Id. STORAGE NAME: h0893.CFS PAGE: 3
DATE: 1/24/2022
Florida’s Child Welfare System
Chapter 39, F.S., creates the dependency system charged with protecting child welfare. Florida’s child
welfare system identifies children and families in need of services through reports to the central abuse
hotline and child protective investigations. The DCF and CBC’s work with those families to address the
problems endangering children, if possible. If the problems cannot be addressed, the child welfare
system finds safe out-of-home placements for these children.
The DCF’s practice model is based on the safety of the child within the home by using in-home
services, such as parenting coaching and counseling, to maintain and strengthen that child’s natural
supports in his or her environment. When children cannot safely remain at home with parents, Florida’s
child welfare system finds safe out-of-home placements for children. After a placement assessment to
determine the most appropriate out-of-home placement, a child may be placed with a relative, fictive
kin, licensed foster parent, in a group home or a residential setting.
5
Residential Treatment Centers
Residential Treatment Centers (RTCs) are licensed under s. 394.875, F.S., and include hospitals
licensed under Ch. 395, F.S., that provide residential mental health treatment. RTC’s include
Specialized Therapeutic Group Homes (STGH), Psychiatric Residential Treatment Facilities (PRFT),
and a new federally defined Qualified Residential Treatment Program (QRTP).
Section 39.407(6), F.S., authorizes the DCF to place a child in its custody in an RTC or a hospital for
residential mental health treatment if the DCF believes the child is emotionally disturbed and needs
residential treatment.
Qualified Residential Treatment Programs
A QRTP is a new designation of a non-family-based placement created by the FFPSA. QRTP’s provide
trauma-informed treatment to children in the child welfare system with serious emotional or behavioral
disorders or disturbances in a residential setting. FFPSA requires QRTP’s to
6
:
Be licensed and nationally accredited.
7
Use a trauma-informed treatment model.
Have registered or licensed nursing or licensed clinical staff on-site and available at all times.
Be inclusive of family members in the treatment process.
Offer at least six months of support after discharge.
All entities operating as an RTC, including a STGH, must first obtain a license from the Agency for
Health Care Administration (AHCA).
8
In Florida, a QRTP is licensed as a STGH by the AHCA and then
credentialed as a QRTP by the DCF after the DCF confirms it meets all federal requirements.
9
For placement in a QRTP, the FFPSA requires a “qualified individual” to conduct an assessment to
determine whether a child’s placement in a QRTP is appropriate. A “qualified individual” is a trained
professional or licensed clinician who is not employed by the state child welfare agency and who is not
connected to, or affiliated with, any placement setting in which children are placed by the state child
welfare agency.
10
The Children’s Bureau within the United States Department of Health and Human
5
R. 65C-28.004, F.A.C.
6
H.R. 1862 of 2018. P.L. 115-123; 42 U.S.C. §672(g).
7
FFPSA requires QRTP’s to be accredited by either the Commission on Accreditation of Rehabilitation Facilities; the Joint Commission
on Accreditation of Healthcare Organizations; the Commission on Accreditation; or any other independent, not-for-profit accrediting
organization approved by the Secretary of the United States Department of Health and Health Services.
8
R. 65E-9.003, F.A.C.
9
R. 65C-46.021, F.A.C.
10
S. 39.407(6)(b), F.S. STORAGE NAME: h0893.CFS PAGE: 4
DATE: 1/24/2022
Services stated that a “qualified individual” could include a licensed social worker or a trained child
welfare worker.
11
Florida currently has five QRTP providers and a 50-bed capacity.
12
Suitability Assessments
When a child is in the child welfare system, a Qualified Evaluator (QE), appointed by the AHCA, must
assess the child in person for suitability before placement in residential treatment, including a QRTP.
Section 39.407(6)(b), F.S, requires the QE to be a psychiatrist or a psychologist licensed in Florida and
who has at least three years of experience in the diagnosis and treatment of serious emotional
disturbances in children and adolescents and who has no actual or perceived conflict of interest with
any inpatient facility or residential treatment center or program.
13
Florida statutes regarding the QE
qualifications exceed that required by the FFPSA for QRTP placements.
Pursuant to s. 39.407(6)(c), F.S., the QE must conduct a personal examination and assessment of the
child and make written findings that:
The child appears to have an emotional disturbance serious enough to require residential
treatment.
The child has been provided with a clinically appropriate explanation of the nature and purpose
of the treatment.
All available modalities of treatment less restrictive than residential treatment have been
considered, and a less restrictive alternative that would offer comparable benefits to the child is
unavailable.
Immediately upon placing the child in an RTC, the DCF must notify and provide a copy of the
assessment to the guardian ad litem and the court having jurisdiction over the child.
14
Children whom the DCF believes would be best served by residential treatment have to wait for an
appointment with a QE so an assessment can be completed.
15
At this time, there are only 18 QE’s
statewide, and providers estimate 400 children need a suitability assessment for placement in a
QRTP.
16
Management of the QE Network
The QE Network contract is held by Magellan Health and was originally managed by AHCA.
17
In 2016,
the Legislature required the AHCA to assign all rights, obligations, and other interest under the contract
pertaining to QE Network services to the DCF.
18
Effective July 1, 2016, the DCF assumed the Magellan
Health contract from AHCA and it is now managed by the DCF.
19
The Legislature did not amend s.
39.407(6)(b), F.S., to reflect this change, and thus the statute still requires AHCA to appoint the QE’s.
The AHCA continues to have statutory authority to adopt rules for the registration of and fee schedule
for QE’s.
Institution for Mental Disease
Since 1965, there has been a large nationwide attempt to “deinstitutionalize” mental health treatment
and decrease the warehousing of mentally ill patients in large institutions like asylums and
11
ACYF-CB-PI-18-07, p. 10-11.
12
Email from John Paul Fiore, Legislative Director, Florida Department of Children and Families, Re; QRTPs, Jan. 20, 2022 (on file with
the Children, Families, and Seniors Subcommittee).
13
S. 39.407(6)(b), F.S.
14
Supra note 10.
15
Florida Department of Children and Families, Agency Bill Analysis for HB 893 (Dec. 10, 2021).
16
Id.
17
Magellan Healthcare, Qualified Evaluator Network (QEN), https://www.magellanofflorida.com/documents/2019/09/florida-qen-
overview.pdf/ (last visited Jan. 20, 2022).
18
Ch. No. 2016-80, L.O.F.
19
Supra note 19. STORAGE NAME: h0893.CFS PAGE: 5
DATE: 1/24/2022
sanitariums.
20
Under s. 1905(a) of the Social Security Act, Medicaid payment for services to persons in
institutions defined as a “Institution for Mental Disease” (IMD’s) is prohibited. This prohibition is called
“the Medicaid IMD exclusion” rule. The IMD exclusion applies to “hospitals, nursing facilities, or other
institutions of more than 16 beds, that provide diagnosis, treatment, or care of persons with mental
diseases, including medical attention, nursing care, or related services.”
The Center for Medicare & Medicaid Services (CMS) issued guidance indicating that the Medicaid IMD
exclusion could apply to QRTP’s.
21
Therefore, QRTP’s with more than 16 beds may be an IMD and
subjected to the Medicaid IMD exclusion if the QRTP is primarily engaged in providing diagnosis,
treatment, or care of individuals with mental illness or substance use disorder.
Effect of Proposed Changes
HB 893 makes changes to Florida law to align with the new requirements of the FFPSA and maximize
federal funding.
The bill amends s. 39.407, F.S., to differentiate between Psychiatric Residential Treatment Facilities
(PRTF) and Specialized Therapeutic Group Homes (STGH)/Qualified Residential Treatment Programs
(QRTP) by setting different requirements for placement assessments. Specifically, the bill amends the
definition in s. 39.407(6)(a), F.S., of “residential treatment” or “residential treatment program” to include
“therapeutic group home” and distinguishes it from a PRTF licensed under s. 394.875, F.S., or a
hospital licensed under Ch. 395, F.S. Under the bill, a “therapeutic group home” is a 24-hour residential
program providing community-based mental health treatment and mental health support services to
children who meet the criteria in s. 394.492 (5) or (6) in a nonsecure, homelike setting that meets the
requirements of a single-family unit or a community residential home as defined in s. 419.001, F.S.
Distinguishing therapeutic group homes from other types of residential treatment allows for a separate
and less intrusive assessment prior to placement in the residential setting.
The bill requires a QE for a STGH (this includes a QRTP which is licensed as a STGH) to be a
psychiatrist, psychologist or a mental health counselor licensed in Florida with at least two years of
experience in the diagnosis and treatment of serious emotional disturbances in children and
adolescents, as opposed to the stricter requirements for a PRTF. This will increase the pool of QE
beyond the 18 currently used for PRTF suitability assessments and create a larger recruitment pool for
STGH/QRTP assessors. The third-party vendor contracted by the DCF for the management of the QE
Network estimates this change will increase the pool of potential QE’s by approximately 2,000.
22
The bill amends s. 39.407(6)(b), F.S., to require DCF, as opposed to AHCA, to appoint the QE. It also
removes AHCA’s rulemaking authority related to the QE Network.
The bill amends s. 39. 407(6)(c), F.S., to remove the requirement that the QE examination of the child
must be a personal examination. This will allow the examination by the QE to be through telehealth.
The bill amends s. 39.407(6)(d), F.S., to require the DCF to provide the guardian ad litem and the court
a copy of the assessment within five days of the DCF’s receipt of the assessment. The DCF will still be
required to notify the guardian ad litem and the court when the child is placed in an RTC but gives more
time to provide a copy of the assessment.
Further, the bill amends s. 39.407(6)(a), F.S., to allow STGH to care for up to 16 unrelated residents.
This increases the number of allowable beds for placements in STGH. This keeps DCF within the
federal IMD rule to maximize Medicaid claiming, but also maximizes capacity of Title IV-E funded
QRTP placements.
The bill takes effect upon becoming a law.
20
Supra note 15.
21
Center for Medicare & Medicaid Services, Qualified Residential Treatment Programs (QRTP) and Serious Mental Illness (SMI) and
Serious Emotional Disturbance (SED) Demonstration Opportunity, Technical Assistance Questions and Answers, Sept. 20, 2019.
22
Supra note 15. STORAGE NAME: h0893.CFS PAGE: 6
DATE: 1/24/2022
B. SECTION DIRECTORY:
Section 1: Amending s. 39.407, F.S., relating to medical, psychiatric, and psychological examination
and treatment of child; physical, mental, or substance abuse examination of person with or
requiring child custody.
Section 2: Provides an effective date.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
None.
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
None.
2. Expenditures:
None.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
None.
D. FISCAL COMMENTS:
None.
III. COMMENTS
A. CONSTITUTIONAL ISSUES:
1. Applicability of Municipality/County Mandates Provision:
Not applicable. The bill does not appear to effect county or municipal governments.
2. Other:
None. STORAGE NAME: h0893.CFS PAGE: 7
DATE: 1/24/2022
B. RULE-MAKING AUTHORITY:
DCF has sufficient rulemaking authority to implement the bill’s provisions.
C. DRAFTING ISSUES OR OTHER COMMENTS:
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES