This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h0391d.HHS
DATE: 4/16/2023
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/CS/HB 391 Home Health Aides for Medically Fragile Children
SPONSOR(S): Health Care Appropriations Subcommittee, Healthcare Regulation Subcommittee, Tramont
TIED BILLS: IDEN./SIM. BILLS: SB 452
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Healthcare Regulation Subcommittee 15 Y, 0 N, As CS Guzzo McElroy
2) Health Care Appropriations Subcommittee 13 Y, 0 N, As CS Smith Clark
3) Health & Human Services Committee Guzzo Calamas
SUMMARY ANALYSIS
Currently, two Medicaid programs that authorize the Agency for Health Care Administration to pay a family member
caregiver to provide home health services to a Medicaid enrollee: the Consumer Directed Care Plus Program (CDC+) and
the Participant Directed Option (PDO). However, the CDC+ program only reimburses for certain personal care services,
and the PDO program only applies to adult long-term care Medicaid enrollees. No family caregiver option is available for
medically fragile children.
CS/CS/HB 391 creates the Home Health Aide for Medically Fragile Children Program to provide an opportunity for family
caregivers to receive training and gainful employment. The bill allows a family caregiver to be reimbursed by Medicaid, as
a home health aide for medically fragile children (HHAMFC), for care provided to a relative who is 21 years old or younger
with an underlying physical, mental, or cognitive impairment, eligible to receive skilled care or respite care services under
the Medicaid program. The bill requires AHCA to establish a fee schedule with a family caregiver reimbursement rate of
$25 per hour for up to 8 hours per day.
The bill authorizes a HHAMFC to perform certain tasks if delated by a registered nurse, such as medication
administration, tasks associated with activities of daily living, maintaining mobility, nutrition and hydration, and safety and
cleanliness. The bill requires services provided by a HHAMFC to result in a reduction in the number of private duty
nursing service hours provided to an eligible recipient. Further, the bill prohibits services provided by a HHAMFC from
duplicating private duty nursing services provided to an eligible recipient.
The bill requires the Agency for Health Care Administration (AHCA), in consultation with the Board of Nursing, to approve
HHAMFC training programs developed by home health agencies which meet certain criteria.
The bill provides civil liability protections for a home health agency (HHA) that terminates or denies employment to a
home health aide for medically fragile children for failure to comply with HHAMFC regulations or whose name appears on
a criminal screening report of the Department of Law Enforcement.
Beginning January 1, 2025, the bill requires AHCA to conduct annual assessments of the Home Health Aide for Medically
Fragile Children Program and report the findings to the Governor and the Legislature.
The bill provides $353,589 in recurring funds and $118,728 in nonrecurring funds from the Health Care Trust Fund, four
Full-Time Equivalent (FTE) positions and associated salary rate, for the purpose of implementing provisions in the bill.
The bill would have an indeterminate, significant, negative fiscal impact on AHCA not addressed in the bill’s appropriation,
and no fiscal impact on local government. See Fiscal Comments.
The bill becomes effective upon becoming law.
STORAGE NAME: h0391d.HHS PAGE: 2
DATE: 4/16/2023
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Florida Medicaid
Medicaid is the health care safety net for low-income Floridians. Medicaid is a partnership of the federal
and state governments established to provide coverage for health services for eligible persons. The
program is administered by the Agency for Health Care Administration (AHCA) and financed by federal
and state funds. AHCA delegates certain functions to other state agencies, including the Department of
Children and Families (DCF), the Department of Health, the Agency for Persons with Disabilities, and
the Department of Elderly Affairs (DOEA).
The structure of each state’s Medicaid program varies and what states must pay for is largely
determined by the federal government, as a condition of receiving federal funds.
1
Federal law sets the
amount, scope, and duration of services offered in the program, among other requirements. These
federal requirements create an entitlement that comes with constitutional due process protections. The
entitlement means that two parts of the Medicaid cost equation – people and utilization – are largely
predetermined for the states. The federal government sets the minimum mandatory populations to be
included in every state Medicaid program. The federal government also sets the minimum mandatory
benefits to be covered in every state Medicaid program. These benefits include home health services.
2
States can add benefits, with federal approval.
States have some flexibility in the provision of Medicaid services. Section 1915(b) of the Social Security
Act provides authority for the Secretary of the U.S. Department of Health and Human Services (HHS) to
waive requirements to the extent that he or she “finds it to be cost-effective and efficient and not
inconsistent with the purposes of this title.” Section 1115 of the Social Security Act allows states to
implement demonstrations of innovative service delivery systems that improve care, increase efficiency,
and reduce costs. These laws allow HHS to waive federal requirements to expand populations or
services, or to try new ways of service delivery.
Florida operates under a Section 1115 waiver to use a comprehensive managed care delivery model
for primary and acute care services, the Statewide Medicaid Managed Care (SMMC) Managed Medical
Assistance (MMA) program.
3
Florida also has a waiver under Sections 1915(b) and (c) of the Social
Security Act to operate the SMMC Long-Term Care (LTC) program to provide long-term care services,
including nursing facility and home and community-based services, to individuals age 65 and over and
individuals age 18 and over who have a disability.
4
Home Health Services
The SMMC program covers home health services that are medically necessary and can be safely
provided to the recipient in their home or in the community, including home health visits (skilled nursing
and home health aide services), private duty nursing (PDN) services, and personal care services.
5
1
Title 42 U.S.C. §§ 1396-1396w-5; Title 42 C.F.R. Part 430-456 (§§ 430.0-456.725) (2016).
2
S. 409.905, F.S.
3
S. 409.964, F.S.
4
Id.
5
Florida Medicaid Home Health Visit Services Coverages Policy (November 2016), available at
https://ahca.myflorida.com/content/download/7034/file/59G-4-130_Home_Health_Visit_Services_Coverage_Policy.pdf (last visited April
4, 2023). STORAGE NAME: h0391d.HHS PAGE: 3
DATE: 4/16/2023
Home Health Aide Visits - Children
Florida Medicaid covers home health aide visits for recipients under the age of 21 who have a medical
condition or disability that substantially limits their ability to perform activities of daily living or
instrumental activities of daily living.
6
The home health visit coverage policy includes up to four hours of
intermittent home health visits per day for any combination of skilled nursing or home health aide
services.
7
Personal Care Services - Children
Personal care services are for Medicaid recipients who require more extensive care than can be
provided through a home health visit. They are provided by unlicensed (HHA) personnel to assist
Medicaid recipients under the age of 21 with activities of daily living and instrumental activities of daily
living to enable recipients to accomplish tasks they would be able to do for themselves if they did not
have a medical condition or a disability. A recipient may receive up to 24 hours or personal care
services per day that have been determined to be medically necessary and that can be safely provided
in the recipient’s home or in the community.
8
Private Duty Nursing Services - Adults
PDN services are skilled nursing services provided to recipients under the age of 21 by a registered
nurse or licensed practical nurse. A recipient may receive up to 24 hours of private duty nursing
services per day if they have a physician’s order for PDN services that are medically necessary and
can be safely provided in their home or their community. The PDN coverage policy also allows for
reimbursement of up to 40 hours per week of an HHA provider for PDN services provided by the parent
or legal guardian of a recipient.
9
The parent or legal guardian must be employed by an HHA and have
a valid license as a registered nurse or licensed practical nurse.
Home Health Aides
Federal Home Health Aide Regulations
Pursuant to the Centers for Medicare and Medicaid Services (CMS) conditions of participation (COPs),
a Medicare certified HHA must ensure that their employees or contractors providing home health aide
services comply with federal training and competency requirements.
10
Training
Home health aide training must include classroom and supervised practical training in which the trainee
demonstrates knowledge while providing services to an individual under the direct supervision of a
registered nurse, or a licensed practical nurse under the supervision of a registered nurse. Classroom
and supervised practical training must total at least 75 hours. A minimum of 16 hours of classroom
training must precede a minimum of 16 hours of supervised practical training as part of the 75 hours.
11
A home health aide training program must address each of the following subject areas:
12
6
Activities of daily living include bathing, dressing, eating, maintaining continence, toileting, and transferring. Instrumental activities of
daily living include grocery shopping, laundry, light housework, meal preparation, medication management, money management,
personal hygiene, transportation, and using the telephone to take care of essential tasks.
7
Supra note 5.
8
Florida Medicaid Personal Care Services Coverage Policy (November 2016), available at
https://ahca.myflorida.com/content/download/7035/file/59G-4-215_Personal_Care_Services_Coverage_Policy.pdf (last visited April 4,
2023).
9
Florida Medicaid Private Duty Nursing Services Coverage Policy (November 2016), available at
https://ahca.myflorida.com/content/download/7036/file/59G-4-261_Private_Duty_Nursing_Services_Coverage_Policy.pdf (last visited
April 4, 2023).
10
42 C.F.R., §484.80.
11
42 C.F.R., §483.152.
12
Id. STORAGE NAME: h0391d.HHS PAGE: 4
DATE: 4/16/2023
Communication and interpersonal skills.
Observation, reporting, and documentation of patient status and the care or service furnished.
Reading and recording vitals.
Basic infection prevention and control procedures.
Basic elements of body functioning and changes in body function that must be reported to an
aide's supervisor.
Maintenance of a clean, safe, and healthy environment.
Safety and emergency procedures.
Hygiene, grooming, and toileting.
Safe transfer techniques and ambulation, and normal range of motion and positioning.
Adequate nutrition and fluid intake.
Recognizing and reporting changes in skin condition and
Any other task that the HHA may choose to have an aide perform as permitted under state law.
Competency Evaluation and In-service Training
An individual may furnish home health services on behalf of an HHA only after that individual has
successfully completed a competency evaluation program.
13
The competency evaluation must be
performed by a registered nurse in consultation with other skilled professionals, as appropriate by
observing an aide's performance of the task with a patient or pseudo-patient.
A home health aide must receive at least 2 hours of in-service training during each 12-month period
under the supervision of a registered nurse. The training may be offered by any organization and may
occur while an aide is furnishing care to a patient. If there has been a 24-month lapse in furnishing
home health aide services for compensation, the individual must complete another training and
competency evaluation program before providing services again.
14
Florida Home Health Aide Regulations
Home health aides are not licensed or certified in Florida. A home health aide that is employed by or
contracted with a licensed HHA must provide documentation of 40 hours of training on topics similar to
the CMS requirements or demonstrate competency through a competency test administered by the
HHA.
15
The competency test is a combination of a written exam and demonstration of skills through the
performance of 14 tasks in the presence of a registered nurse or a licensed practical nurse under the
supervision of a registered nurse.
Under current law, a registered nurse is authorized to delegate any task, including medication
administration, to a home health aide, if the registered nurse determines that the home health aide is
competent to perform the task, the task is delegable under federal law, and the task:
16
Is within the nurse’s scope of practice;
Frequently recurs in the routine care of a patient or group of patients;
Is performed according to an established sequence of steps;
Involves little or no modification from one patient to another;
May be performed with a predictable outcome;
Does not inherently involve ongoing assessment, interpretation, or clinical judgement; and
Does not endanger a patient’s life or well-being.
Family Caregiver Programs
Nearly half of children and youth with special health care needs receive family-provided care at home.
17
Family caregivers tend to have financial challenges due to reduced or lost employment, and forego an
13
42 C.F.R., §483.40.
14
Id.
15
Rule 59A-8.0095(5), F.A.C.
16
S. 464.0156, F.S. STORAGE NAME: h0391d.HHS PAGE: 5
DATE: 4/16/2023
estimated $17.6 billion in earnings per year.
18
Family caregivers of children and youth with special
health care needs also tend to develop health issues of their own from the enduring physical and
mental strains imposed on the them in caring for their children.
19
Family caregivers report a need for
information related to managing stress, finding time for oneself, and balancing work and family
responsibilities, but what they report to need the most are policies that offer financial support for the
caregiving they provide.
20
States can use Medicaid funds to pay family caregivers of children and youth with special health care
needs for the assistance they provide with activities of daily living or instrumental activities of daily living
through state plan options and federal Medicaid waiver authorities that allow for participant-directed
(also referred to as self-directed) services. Through these options, Medicaid enrollees or their
representatives have “employer authority” and are able to choose who provides their Medicaid-funded
services, which may include a family caregiver. Florida already allows this under the CDC+ program for
children with developmental disabilities and under the Participant Direction Option program for adult
LTC recipients.
States can also use Medicaid funds to pay family caregivers to provide certain medical assistance tasks
such as administering medications. When provided in the home, these services are considered home
health services, which are federally defined to include nursing services, medical supplies and
equipment, and home health aide services, physical and occupational therapy, speech pathology and
audiology services provided by an HHA.
21
These services may be covered by a state’s mandatory
Medicaid State Plan Home Health benefit or by the Early, Periodic, Screening, Diagnosis and
Treatment (EPSDT) benefit.
22
A state’s Medicaid State Plan Home Health benefit can also be used to reimburse family caregivers of
children with special needs for skilled nursing, home health aide, and other therapeutic services.
However, according to a recent study on state approaches to reimbursing family caregivers of children
with special needs, these services require the provider to meet certain professional qualifications and,
often, to be employed by a HHA, both of which may pose barriers for family caregivers.
23
Additionally,
few states allow home health state plan benefits to be participant-directed, as a result, children or their
legal representatives may not have the employer authority to hire their family caregiver to provide
services.
24
Instead, states can modify provider qualifications to reduce education and training barriers
for appropriate services, and develop policies that are designed to support family caregivers in gaining
the necessary credentials to provide reimbursable services for family caregivers. Three states have
used this method to establish family caregiver programs—Colorado, Arizona, and Missouri.
25
Family Caregiver Programs in Florida
Consumer Directed Care Plus Program
17
Olivia Randi, Eskedar Girmash, and Kate Honsberger, State Approaches to Reimbursing Family Caregivers of Children and Youth
with Special Health Care Needs through Medicaid, National Academy for State Health Policy (January 15, 2021), available at
https://nashp.org/state-approaches-to-reimbursing-family-caregivers-of-children-and-youth-with-special-health-care-needs-through-
medicaid/ (last visited April 4, 2023).
18
John Romley, Aakash Shah, Paul Chung, Marc Elliott, Katherine Vestal, Mark Schuster, Family-Provided Health Care for Children
with Special Health Care Needs. American Academy of Pediatrics (January 2017).
19
National Alliance for Caregiving and AARP. Caregivers of Children: A Focused look at Those Caring for A Child with Special Needs
Under the Age of 18. November 2009, available at https://www.caregiving.org/wp-
content/uploads/2020/05/Report_Caregivers_of_Children_11-12-09.pdf (last visited April 4, 2023).
20
Cara Coleman, Not Just Along for The Ride: Families Are The Engine That Drives Pediatric Home Health Care, Health Affairs Blog
(April 18, 2019), available at https://www.healthaffairs.org/do/10.1377/hblog20190415.172668/full/ (last visited April 4, 2023).
21
42 C.F.R. §440.70.
22
Through the EPSDT benefit, state Medicaid agencies are required to provide children under age 21 with all Medicaid services that
can be covered through federal Medicaid law. See Center for Medicaid and CHIP Services, Early and Periodic Screening, Diagnostic,
and Treatment, available at https://www.medicaid.gov/medicaid/benefits/early-and-periodic-screening-diagnostic-and-
treatment/index.html (last visited April 4, 2023).
23
Supra note 17.
24
Id.
25
Id. STORAGE NAME: h0391d.HHS PAGE: 6
DATE: 4/16/2023
The Agency for Persons with Disabilities is responsible for the operation of the Developmental
Disabilities Individual Budgeting (iBudget) Waiver.
26
The purpose of the iBudget Waiver is to provide
home and community-based supports and services to eligible recipients with developmental disabilities
living at home or in a home-like setting utilizing an individual budgeting approach.
The Consumer Directed Care Plus Program (CDC+), authorized by a Federal 1915(j) Medicaid State
Plan Amendment,
27
permits recipients of all ages with a developmental disability to self-direct their own
provider for personal care assistance services, which may include a legally liable relative of the
recipient.
28
Personal care assistance services include assistance with eating, meal preparation, bathing,
dressing, personal hygiene, and activities of daily living, and housekeeping if considered essential to
the health, safety, and welfare of the recipient. To be eligible for the CDC+ Program, a recipient must:
29
Be enrolled in the iBudget Waiver;
Reside in their own home or the home of a relative; and
Not have been previously disenrolled from the CDC+ Program due to their mismanagement or
inappropriate use of Medicaid funds.
The relative of a recipient is not required to be licensed to provide personal care assistance services,
but they must be at least 16 years old and have at least one year of experience working in a medical,
psychiatric, nursing or childcare setting or working with individuals with developmental disabilities—
routine care provided to a relative who has a developmental disability satisfies this requirement.
30
Participant Direction Option
The participant direction option (PDO) is a service delivery model that enables LTC adult beneficiaries
to exercise decision-making over allowable services and how those services are delivered, including
the ability to hire and fire service providers.
31
Enrollees choosing to participate in the PDO service
delivery model actively manage their own health care and are responsible for hiring and managing their
direct service worker, who may be a neighbor, family member, or friend.
32
The LTC plan is responsible for implementing and managing the PDO and must ensure the PDO is
available to all enrollees who have one or more of the following services on their plan of care and who
live in their own home or family home: adult companion care, attendant nursing care, homemaker
services, intermittent and skilled nursing, or personal care. Direct service workers who provide
attendant care or intermittent and skilled nursing services must be a registered nurse or a licensed
practical nurse. Direct service workers providing adult companion, homemaker, or personal care
services are not required to be licensed or certified.
The PDO service delivery model is not available to children.
No family caregiver option is available for medically fragile children.
Direct Care Workforce Survey
26
S. 393.0662, F.S.
27
Federal 1915(j) waivers authorize state Medicaid programs to allow recipients to self-direct personal assistance services and hire
legally liable relatives to provide such services. See https://www.medicaid.gov/medicaid/home-community-based-services/home-
community-based-services-authorities/self-directed-personal-assistant-services-1915-j/index.html (last visited April 4, 2023).
28
Florida Medicaid Consumer-Directed Care Plus Program Coverage, Limitations, and Reimbursement Handbook (October 2015)
available at https://apd.myflorida.com/cdcplus/docs/CDC_Plus_Program_Handbook_2015.pdf (last visited April 4, 2023).
29
Id.
30
Id.
31
Agency for Health Care Administration, Participant Direction Option Manual, available at
https://ahca.myflorida.com/medicaid/statewide-medicaid-managed-care/long-term-care-plans2 (last visited April 4, 2023).
32
Id. Direct service worker means the employee(s), directly-hired by a participant, providing PDO services as authorized on the care
plan. The direct service worker(s) may be any qualified individual chosen by the participant, including a neighbor, family member, or
friend. The direct service worker(s) is paid by the Managed Care Plan based on a set rate. STORAGE NAME: h0391d.HHS PAGE: 7
DATE: 4/16/2023
Current law requires nursing homes, assisted living facilities, HHAs, hospices, and homemaker and
companion services providers to complete a survey on their direct care workforce upon licensure
renewal. The survey includes the following information:
Number of registered nurse and direct care workers employed by the licensee;
Turnover and vacancy rates of registered nurses and direct care workers and contributing
factors;
Average wage for registered nurses and each category of direct care worker for employees and
contractors of the licensee;
Employment benefits for registered nurses and direct care workers and average cost to the
employer and employee; and
Type of availability of training for registered nurses and direct care workers.
AHCA is required to review and analyze the data received at least monthly and publish the results of
the analysis on its website.
Effect of the Bill
Home Health Aides for Medically Fragile Children
CS/CS/HB 391 creates the Home Health Aide for Medically Fragile Children Program in response to
the national health care provider shortage and its impact on medically fragile children and their family
caregivers to provide an opportunity for family caregivers to receive training and gainful employment.
The bill allows a family caregiver to be reimbursed by Medicaid, as a home health aide for medically
fragile children (HHAMFC). To qualify, the care must be provided to a relative who is 21 years old or
younger with an underlying physical, mental, or cognitive impairment that prevents him or her from
safely living independently. The relative must also be eligible to receive skilled care or respite care
services under the Medicaid program.
Authorized Tasks
The bill authorizes a HHAMFC to perform certain tasks if delegated by a registered nurse, including
medication administration
33
and tasks associated with:
Activities of daily living, including bathing, dressing, eating, maintaining continence, toileting,
and transferring;
Maintaining mobility;
Nutrition and hydration;
Assistive devices;
Safety and cleanliness;
Data gathering;
Reporting abnormal signs and symptoms;
Postmortem care;
End-of-life care;
Patient socialization and reality orientation;
Cardiopulmonary resuscitation and emergency care;
Residents’ or patients’ rights; and
Documentation of services performed.
The bill requires services provided by a HHAMFC to result in a reduction in the number of private duty
nursing service hours provided to an eligible recipient. Further, the bill prohibits services provided by a
HHAMFC from duplicating private duty nursing services provided to an eligible recipient.
33
Including oral, transdermal, ophthalmic, otic, rectal, inhaled, enteral, or topical prescription medications. STORAGE NAME: h0391d.HHS PAGE: 8
DATE: 4/16/2023
Eligibility Requirements
The bill authorizes an HHA to employ a HHAMFC who meets certain eligibility requirements.
Specifically, the individual must:
Be at least 18 years old;
Be a family caregiver of an eligible relative;
Demonstrate a minimum ability to read and write;
Successfully pass background screening requirements; and
Complete an approved training program or have graduated from an accredited prelicensure
nursing education program and are waiting to take the state licensing exam.
Training Requirements
The bill requires AHCA, in consultation with the Board of Nursing, to approve HHAMFC training
programs developed by HHAs. A training program must consist of at least 85 hours and include at least
40 hours of theoretical instruction in nursing, 20 hours of skills training on basic nursing, 16 hours of
clinical training under the direct supervision of a licensed registered nurse, and an unspecified minimum
number of hours of training on HIV/AIDS infections. Additionally, a HHAMFC must also obtain and
maintain a current certificate in cardiopulmonary resuscitation (CPR) and complete 12 hours of annual
in-service training each 12-month period. The training on HIV/AIDS and CPR may be counted towards
the 12 hours of in-service training.
The 40 hours of theoretical instruction in nursing must include the following topics:
Person-centered care;
Communication and interpersonal skills;
Infection control;
Safety and emergency procedures;
Assistance with activities of daily living;
Mental health and social service needs;
Care of cognitively impaired individuals;
Basic restorative care and rehabilitation;
Patient rights and confidentiality of personal information and medical records; and
Relevant legal and ethical issues.
The 20 hours of skills training must consist of basic nursing skills training in the following areas:
Hygiene, grooming, and toileting;
Skin care and pressure sore prevention;
Nutrition and hydration;
Measuring vital signs, height, and weight;
Safe lifting, positioning, and moving of patients;
Wound care;
Portable oxygen safety and other respiratory procedures;
Tracheostomy care;
Enteral care and therapy;
Peripheral intravenous assistive activities and alternative feeding methods; and
Urinary catheterization and ostomy care.
The bill requires a HHAMFC to complete the six hours of training required by current law for home
health aides prior to administering medication upon delegation by a registered nurse.
The bill requires training to be offered in various formats, and any interactive instruction must be
provided during various times of the day. The bill requires HHAs to provide the training for free to a
parent, guardian, or family member of a medically fragile child. If a HHAMFC allows 24 months to pass STORAGE NAME: h0391d.HHS PAGE: 9
DATE: 4/16/2023
without providing any personal care services to an eligible relative, the family caregiver must retake all
required training.
Liability and Confidentiality
The bill provides civil liability protections for an HHA that terminates or denies employment to a home
health aide for medically fragile children for failure to comply with HHAMFC regulations or whose name
appears on a criminal screening report of the Department of Law Enforcement.
The bill prohibits an HHA from using the criminal records or juvenile records of a vulnerable adult for
any purpose other than determining if the individual meets the requirements of the Home Health Aide
for Medically Fragile Children Program.
Annual Report
Beginning January 1, 2025, the bill requires AHCA to conduct annual assessments of the Home Health
Aide for Medically Fragile Children Program and report their findings by January 1 of each year to the
Governor, the President of the Senate and the Speaker of the House of Representatives. The bill
requires the report to include an assessment of caregiver satisfaction with the program, identify
additional support that may be needed by home health aides for medically fragile children, and assess
the rate and extent of the hospitalization of children receiving home health services from a HHAMFC
compared to those receiving traditional home health services.
Direct Care Workforce Survey
Current law requires nursing homes, HHAs, hospices, and homemaker and companion services
providers to complete a workforce survey upon each biennial licensure renewal. The bill requires HHAs
to include data on home health aides for medically fragile children in their direct care workforce
surveys.
Implementation
The bill authorizes AHCA to modify any state Medicaid plans and implement any federal waivers
necessary to implement the Home Health Aide for Medically Fragile Children Program.
The bill requires AHCA to establish a fee schedule for HHAs to pay home health aides for medically
fragile children at a rate of $25 per hour for up to 8 hours per day.
The bill becomes effective upon becoming a law.
STORAGE NAME: h0391d.HHS PAGE: 10
DATE: 4/16/2023
B. SECTION DIRECTORY:
Section 1: Amends s. 400.462, F.S., relating to definitions.
Section 2: Amends s. 400.464, F.S., relating to home health agencies to be licensed; expiration of
license, exemptions; unlawful acts; penalties.
Section 3: Amends s. 400.476, F.S., relating to staffing requirements, notifications; limitations on
staffing services.
Section 4: Creates s. 400.4765, F.S., relating to home health aide for medically fragile children
program.
Section 5: Amends s. 400.489, F.S., relating to administration of medication by a home health aide;
staff training requirements.
Section 6: Amends s. 400.490, F.S., relating to nurse-delegated tasks.
Section 7: Creates s. 400.54, F.S., relating to annual assessment of the home health aide for
medically fragile children program.
Section 8: Amends s. 408.822, F.S., relating to direct care workforce survey.
Section 9: Amends s. 464.0156, F.S., relating to delegation of duties.
Section 10: Provides an appropriation to implement the bill.
Section 11: Provides the bill will take effect upon becoming law.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
The bill provides $353,589 in recurring funds and $118,728 in nonrecurring funds from the Health
Care Trust Fund, four Full-Time Equivalent (FTE) positions and 186,483 of associated salary rate,
for the purpose of implementing provisions in the bill.
Additionally, AHCA expects the bill to have a negative fiscal impact on the Medicaid program, but
the extent of the impact is indeterminate. The bill requires AHCA to adopt a minimum rate of $25 for
a maximum of 8 hours per day for home health services provided by home health aides for
medically fragile children. According to AHCA, “current Medicaid fee schedules for applicable
services as specified in AHCA’s promulgated fee schedules are $18.04 per visit for skilled nursing
services and $17.32 per hour for a home health service provider.
34
The exact extent of the fiscal
impact is indeterminate because AHCA does not have data identifying those Medicaid recipients
with a family caregiver that would like to or currently meet the qualifications specified in the bill. The
bill does not address a limit on the number of hours per year, but rather sets a maximum of eight
hours per day per provider. This could increase the total number of hours to 2,920. Currently, there
are 5,072 recipients that would fall into this population.”
35
AHCA’s fiscal analysis is based on the assumption that all recipients who choose to enroll in the
Home Health Aides for Medically Fragile Children Program are not currently receiving home health
services under the Medicaid program, which may be in error.
The following chart highlights the potential increase in Medicaid spending based on the percent of
participants eligible for this option as outlined in bill:
36
34
Agency for Health Care Administration, Agency Analysis of 2023 HB 391 (March 1, 2023), on file with the House Healthcare
Regulation Subcommittee
35
Id.
36
Id. STORAGE NAME: h0391d.HHS PAGE: 11
DATE: 4/16/2023
Participation
%
Additional Cost at
2080 hours or 40
hours per week.
Additional Cost at
Number of hours
Claimed in SFY21-22
2219 hours
Additional Cost at
2920 hours or 8
hours per day/ 365
Days per year
100% $ 104,395,766 $ 122,039,870 $ 210,907,766
75% $ 78,296,825 $ 91,529,903 $ 158,180,825
50% $ 52,197,883 $ 61,019,935 $ 105,453,883
25% $ 26,098,942 $ 30,509,968 $ 52,726,942
10% $ 10,439,577 $ 12,203,987 $ 21,090,777
5% $ 5,219,788 $ 6,101,994 $ 10,545,388
1% $ 1,043,958 $ 1,220,399 $ 2,109,078
The appropriation in the bill funds the administrative costs of the new program, but does not address
the indeterminate utilization costs estimated in the table above.
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
None.
2. Expenditures:
None.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
None.
D. FISCAL COMMENTS:
Future expenditures related to the HHAMFC Program would be considered by the Social Services
Estimating Conference in the Medicaid Expenditures forecast.
III. COMMENTS
A. CONSTITUTIONAL ISSUES:
1. Applicability of Municipality/County Mandates Provision:
Not applicable. The bill does not appear to affect county or municipal governments.
2. Other:
None.
B. RULE-MAKING AUTHORITY:
The bill provides sufficient rule-making authority to AHCA to implement the provisions of the bill.
C. DRAFTING ISSUES OR OTHER COMMENTS:
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES
On March 28, 2023, the Healthcare Regulation Subcommittee adopted an amendment and reported the bill
favorably as a committee substitute. The amendment: STORAGE NAME: h0391d.HHS PAGE: 12
DATE: 4/16/2023
Required services provided by a home health aide for medically fragile children to reduce an eligible
relative’s private duty nursing service hours; and
Prohibited services provided by a home health aide for medically fragile children from duplicating
private duty nursing services.
On April 12, 2023, the Health Care Appropriations Subcommittee adopted an amendment and reported the
bill favorably as a committee substitute. The amendment provided funding authority, positions and
associated salary rate, to implement provisions in the bill.
This analysis is drafted to the committee substitute as passed by the Health Care Appropriations
Subcommittee.