This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h0831b.HCA
DATE: 3/28/2023
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: HB 831 Medicaid Recipients with Developmental Disabilities
SPONSOR(S): Duggan
TIED BILLS: IDEN./SIM. BILLS: SB 1084
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Healthcare Regulation Subcommittee 14 Y, 0 N Calamas McElroy
2) Health Care Appropriations Subcommittee Smith Clark
3) Health & Human Services Committee
SUMMARY ANALYSIS
The Florida Medicaid program provides health care coverage for low-income and disabled Floridians, in
financial partnership with the federal government. Medicaid provides both acute care medical services, and
long-term care services for elderly and disabled people at risk of nursing home admission. With few
exceptions, Medicaid provides services through a comprehensive managed care model, which integrates acute
care and long-term care.
The Florida home- and community-based services (HCBS) Medicaid waiver program, known as iBudget
Florida, provides Medicaid-covered, non-acute, services for persons with developmental disabilities. iBudget
services are designed to help people achieve the greatest potential for independent and productive living, while
avoiding costly institutionalization. While most of the Medicaid program uses a managed care model,
managed care is not used for HCBS; even for acute care services, iBudget enrollees may choose to enroll in a
managed care plan, or remain in the traditional, fee-for-service, Medicaid system without acute care
coordination.
Long-term care and HCBS services are not available in traditional Medicaid; they are authorized only by
federally approved state waivers. Long-term care and HCBS services have some similarities; both are non-
acute care, and both are intended to avoid institutionalization and assist people to remain in the community.
The iBudget federal waiver allows the state to limit the number of people served, as determined by state
funding levels. The iBudget currently maintains a waitlist of people eligible for enrollment, but beyond the level
of funding for the waiver program.
HB 831 directs the Agency for Health Care Administration (AHCA) to establish a pilot program in Miami-Dade
County for a managed care model of service delivery for persons with developmental disabilities. AHCA must
contract with a Medicaid managed long-term care plan to provide the services, which must be a provider
service network owned in part by health care practitioners with experience serving persons with developmental
disabilities. The plan must provide comprehensive, integrated care, including acute care and home- and
community-based developmental disability services, rather than the current model of separate acute and
HCBS care. The plan will be available, on a voluntary basis, only for people on the iBudget waitlist.
The bill requires AHCA to contract for an independent evaluation of the qualified long-term care plan and
submit a report to the legislature by October 31, 2024.
The bill has an indeterminate, but likely significant, negative fiscal impact on state expenditures, and no fiscal
impact on local government. See Fiscal Analysis.
The bill provides an effective date of July 1, 2023. STORAGE NAME: h0831b.HCA PAGE: 2
DATE: 3/28/2023
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 physician services,
hospital services, home health services, and family planning.
2
States can add benefits, with federal
approval. Florida has added many optional benefits, including prescription drugs, adult dental services,
and dialysis.
3
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.
4
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.
5
Florida Medicaid does not cover all low-income Floridians. Current eligibility prioritizes low-income
children, disabled persons, and elders, and sets income eligibility by reference to the annual federal
poverty level. For some groups, clinical eligibility provisions apply, as well.
The Florida Medicaid program covers over 5.5 million low-income individuals, including approximately
2.5 million children, or 54%, of the children in Florida.
6
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. 409.906, F.S.
4
S. 409.964, F.S.
5
Id.
6
Agency for Health Care Administration, Presentation to the House Healthcare Regulation Subcommittee, Jan. 18, 2023. STORAGE NAME: h0831b.HCA PAGE: 3
DATE: 3/28/2023
Statewide Medicaid Managed Care (SMMC)
Florida delivers medical assistance to most Medicaid recipients – approximately 78% - using a
comprehensive managed care model, the SMMC program.
7
The SMMC program was intended to
provide comprehensive, coordinated benefits coverage to the Medicaid population, leveraging
economic incentives to ensure provider participation and quality performance impossible under the
former, federally prescribed, fee-for-service delivery model.
The SMMC program has three components: the integrated Managed Medical Assistance (MMA)
program that provides primary care, acute care and behavioral health care services; the Long-Term
Care (LTC) program
8
that provides long-term care services, including nursing facility and home- and
community-based services; and the dental component.
Services in SMMC are delivered by two types of managed care plans: traditional managed care
organizations and provider service networks (PSNs). Traditional managed care organizations, such as
HMOs, are reimbursed as prepaid plans – they are risk-bearing entities that are paid capitated rates
(prospective, per-member, per-month payments) by AHCA. PSNs are managed care plans controlled
by health care providers, such as physician groups or hospitals. Because health care practitioners and
facilities did not previously operate managed care plans or use capitated payment arrangements,
SMMC allowed an alternative risk-bearing arrangement for PSNs.
AHCA contracts with managed care plans on a statewide and regional basis, in sufficient numbers to
ensure choice. The cyclical Medicaid procurement process ensures plans offer competitive benefit
designs and prices. In addition, plans compete for consumer choice: while Medicaid requires a basic
benefit package, and regulates the adequacy of plans’ provider networks, plans can add to their benefit
packages and offer provider networks attractive to Medicaid recipients when choosing a plan.
AHCA began the next procurement process in 2022 for implementation in the 2025 plan year, and
plans to issue the procurement solicitation documents imminently.
Long-Term Care
Federal Medicaid law establishes coverage for institutional care, such as nursing home care and
residential institutions for people with developmental disabilities, but does not allow federal dollars to be
spent on alternatives to such care. Those alternatives include home- and community-based services
designed to keep people in their homes and communities instead of going into an institution when they
need higher levels of care. This federal spending limitation creates a bias toward institutional care, and
toward acute care, rather than allowing the non-acute supports that prevent institutionalization.
Florida obtained a federal waiver to allow the state Medicaid program to cover other kinds of long-term
care services for elders and people with disabilities, to prevent admission into a nursing home. Those
non-institutional, often non-acute, long-term care benefits are listed below.
7
Id.
8
The LTC program provides services in two settings: nursing facilities or home- and community-based services (HCBS) provided in a recipient’s home,
an assisted living facility, or an adult family care home. Enrollment in the LTC program is based on a clinical priority system and includes a w ait list. The
state is approved for 62,000 recipients in the HCBS portion of LTC. In order to be eligible for the program, a recipient must be both clinically eligible
under s. 409.979, F.S., and financially eligible for Medicaid under s. 409.904, F.S. STORAGE NAME: h0831b.HCA PAGE: 4
DATE: 3/28/2023
SMMC Long-Term Care Mandatory Benefits
Services provided in an ALF Physical therapy
Hospice services Intermittent and skilled nursing
Adult day care Medication administration
Personal care Medication management
Home accessibility adaption Nutritional assessment and risk reduction
Behavior management Caregiver training
Home-delivered meals Respite care
Case management Personal emergency response system
Occupational therapy Transportation
Speech therapy Medical equipment and supplies
Respiratory therapy
Medicaid Home- and Community-Based Waiver for Persons with Developmental Disabilities
Under federal law, fee-for-service Medicaid provides coverage for health care services to cure or
ameliorate diseases; generally, Medicaid does not cover not services that will not cure or mitigate the
underlying diagnosis, or social services. However, people with developmental disabilities, while
certainly requiring traditional medical services, need other kinds of services to maintain their
independence and avoid institutionalization. Home- and community-based services (HCBS) are an
alternative to institutionalizing people with developmental disabilities.
To obtain federal Medicaid funding for HCBS, Florida obtained a Medicaid waiver.
9
This allows
coverage of non-medical services to avoid institutionalization, and allows the state to limit the scope of
the program to the number of enrollees deemed affordable by the state. In this way, the HCBS waiver is
not an entitlement; it is a first-come-first-served, slot-limited program.
Under the HCBS waiver, known as iBudget Florida, serves eligible
10
persons with developmental
disabilities. Eligible diagnoses include disorders or syndromes attributable to intellectual disability,
cerebral palsy, autism, spina bifida, Down syndrome, Phelan-McDermid syndrome, or Prader-Willi
syndrome. The disorder must manifest before the age of 18, and it must constitute a substantial
handicap that can reasonably be expected to continue indefinitely.
11
The Agency for Persons with Disabilities (APD) administers the iBudget program, offering 27 supports
and services delivered by contracted service providers to assist individuals to live in their community.
Examples of waiver services are residential habilitation, behavioral services, companion, adult day
training, employment services, and physical therapy.
12
While providers and individual support coordinators each have a role in helping the iBudget enrollee
assess and coordinate their care, the program essentially operates as a fee-for-service program, with
no comprehensive care management in the traditional sense. The HCBS services are not integrated
with acute medical services or behavioral health services, as those Medicaid services are administered
by AHCA (usually through the fee-for service model, not the managed care model).
Historically, despite the utilization management tools authorized in law and the entitlement flexibilities
provided by the federal waiver, and despite legislative funding increases, APD has frequently been
unable to manage the waiver program within the budget appropriated by the legislature, resulting in
significant deficit spending.
13
9
Florida Developmental Disabilities Individual Budgeting Waiver (0867.R02.00), March 4, 2011, authorized under s. 1915b of the Social Security Act.
10
The HCBS w aiver retains the Medicaid requirement that enrollees be low-income, but measures only the developmentally disabled person’s income;
not the income generated by the w hole household.
11
S. 393.063(12), F.S.
12
Agency for Persons with Disabilities, Quarterly Report on Agency Services to Floridians w ith Developmental Disabilities and Their Costs: First Quarter
Fiscal Year 2022-2023, Nov. 15, 2023, available at
https://apd.myflorida.com/publications/reports/docs/FY%202023%20Quarterly%20Report%201st%20Quarter%20report.pdf (last viewed Mar. 24, 2023).
13
For example, the legislature made retroactive appropriations to address APD deficits that occurred in FY 17-18 ($56,895,137), FY 2018-2019
($107,848,988), and FY 2019-2020 ($133,505,542). See Sections 30, 30, and 29, respectively, of the respective General Appropriations Acts in those
years. STORAGE NAME: h0831b.HCA PAGE: 5
DATE: 3/28/2023
In 2019, the legislature directed the agency to implement better monitoring and accounting procedures,
and to take corrective action when deficits are projected to develop. In addition, APD was required to
develop a plan to redesign the program if a deficit were to re-occur in the 2018-2019 fiscal year.
14
APD
did generate a deficit that year; however, the submitted redesign plan promised to stay within the
appropriated budget only if that budget were significantly increased.
15
For FY 2022-2023, the legislature appropriated $1,871,531,214 to APD for the iBudget waiver program,
of which $742,997,892 are state funds.
16
Currently, the program serves over 35,300 enrolled people.
17
iBudget Waiver Waitlist
APD maintains a waitlist of people who would like to enroll in the waiver. Currently, the waitlist includes
22,535 people. About 660 of those receive other, limited, services from APD, and over 9,000 people on
the waitlist are otherwise eligible for, and receive, Medicaid coverage for medical care. About 13,500
people on the waiver waitlist receive no APD or Medicaid services.
18
As new funding becomes available, APD enrolls people from the waitlist in a statutory order of priority in
seven categories, described below.
19
Category Description
1 Crisis, as defined by APD
2
Individuals:
From the child welfare system with an open case who are either:
o Transitioning out of the child welfare system at the finalization of an adoption, a
reunification with family members, a permanent placement with a relative, or a
guardianship with a nonrelative; or
o At least 18 years but not yet 22 years of age and who need both waiver services and
extended foster care services; or
18-21 years old who chose not to remain in extended foster care.
3
Individuals:
Whose caregiver has a documented condition that is expected to render the caregiver
unable to provide care within the next 12 months and for whom a caregiver is required but
no alternate caregiver is available;
At substantial risk of incarceration or court commitment without supports;
Whose documented behaviors or physical needs place them or their caregiver at risk of
serious harm and other supports are not currently available to alleviate the situation; or
Who are identified as ready for discharge within the next year from a state mental health
hospital or skilled nursing facility and who require a caregiver but for whom no caregiver is
available or whose caregiver is unable to provide the care needed.
4
Individuals whose caregivers are 70 years of age or older and for whom a caregiver is required
but no alternate caregiver is available.
5
Individuals expected to graduate from high school within the next 12 months who need support
to obtain a meaningful day activity, maintain competitive employment, or attend postsecondary
education.
6 Individuals age 21 or older who do not meet the criteria for Categories 1-5.
7 Individuals under age 21 who do not meet the criteria for Categories 1-4.
14
Ch. 2019-116, s. 26, Law s of Fla.
15
Agency for Persons with Disabilities and Agency for Health Care Administration, 2029 iBudget Waiver Redesign, Sept. 30, 2019.
16
Ch. 2022-156, Law s of Fla., Specific Appropriation 245.
17
Supra, note 12.
18
Id.
19
S. 393.065(5), F.S. STORAGE NAME: h0831b.HCA PAGE: 6
DATE: 3/28/2023
The chart below indicates the percent of people in each category on the current waitlist.
APD rarely moves beyond Category 1 in enrolling people off the wait list. In Fiscal Years 2020-2021
and 2021-2022, for example, APD enrolled a total of 2,646 new enrollees in the waiver program. Of
those, 1,841 (70%) were Category 1 – crisis – enrollees.
20
Medicaid Coverage for iBudget Enrollees
iBudget waiver benefits include Medicaid coverage for medical services, administered by AHCA. The
vast majority of full-coverage Medicaid recipients receive services through the SMMC managed care
model, in which the recipient can choose from different health plans – including HMOs and PSNs – to
provide their care. However, under current law, using the managed care model is an option for iBudget
enrollees; not a requirement. iBudget participants can opt to use the traditional fee-for-service model of
service delivery.
21
Because clinical services and home- and community-based services are provided by two different
programs in two different state agencies, these services are not integrated or managed as a whole
service for the individual.
HCBS and Managed Care Models
Some states use managed care models for HCBS for persons with developmental disabilities, in
varying forms.
Iowa and Kansas use a long-term care managed care model to provide developmental disability
services. These states use a single, risk-bearing, managed care plan to coordinate all services for this
20
Supra note 12. Of the 2,646 new enrollees, 182 w ere in Category 2 (children aging out of the child w elfare system); the remainder w ere in special
categories authorized by the legislature to jump the queue (military dependents, people w ith Phelan-McDermid Syndrome, and people in ICFs or nursing
facilities), see s. 393.064(6), (7), F.S.
21
S. 409.972(1)(e), F.S. STORAGE NAME: h0831b.HCA PAGE: 7
DATE: 3/28/2023
population – acute care, behavioral health and long-term care services. Tennessee takes a similar
approach, but its managed care plans do not bear risk.
22
New York obtained a federal waiver to transition the Medicaid developmental disability population into
managed care in a phased model, beginning with integrated care coordination under a single,
comprehensive plan. In addition, New York offers operates a service delivery model which fully
integrates with Medicare coverage (for people with dual eligibility), offering acute, long-term care and
habilitation services.
23
Using managed care for the developmental disability population requires careful adaptation of acute
care models to address factors that differentiate this population from a typical long-term care
population. These factors include: the longer length of time individuals will require these services, often
for a lifetime; the role of community services and supports, and the need to integrate them into the
model; and the unique developmental disability provider community, composed of smaller
organizations exclusively dependent on government funding and inexperienced at navigating a
managed care environment; among other differentiating factors.
24
Florida does not use a risk-based managed care model for HCBS services, and the Medicaid acute
care managed care model is rarely used by iBudget enrollees. Medicaid acute care services and HCBS
services are not integrated, or coordinated by any single entity for the individual enrollee.
Effect of Proposed Changes
The bill would create a pilot program in Miami-Dade County establishing a managed care model for
integrating medical care and home- and community-based services for persons with developmental
disabilities. To implement the pilot program, AHCA will need to modify the current SMMC waiver and
obtain federal approval.
The bill requires AHCA to contract with a long-term care plan in Miami-Dade County to integrate
medical services and HCBS in one coverage plan. Benefits would include traditional Medicaid medical
benefits, long-term care benefits provided in the current Medicaid managed long-term care program,
and the HCBS benefits currently provided through the iBudget waiver. The selected qualified plan will
be compensated based on a risk-adjusted capitated rate.
Participation in the pilot project would be voluntary and would only be offered to people on the iBudget
waitlist. The maximum number of enrollees would be limited to the amount specified in the General
Appropriations Act.
The contracted long-term care plan must be a provider service network whose owners include health
care providers with experience serving iBudget waiver recipients; this ensures the PSN has experience
with this unique population, not only traditional long-term care (with its focus on elderly people). The bill
requires the plan to establish an individualized care plan for each enrollee, evaluate and update it at
least quarterly, or as changes in conditions and circumstances warrant, and provide services in
accordance with that care plan.
The bill requires the managed care plan to submit financial reports, and requires the plans to participate
in the achieved savings rebate program
25
, consistent with the requirements for other Medicaid
managed care plans.
22
National Association of States United for Aging and Disabilities, MLTSS Institute, “MLTSS for People w ith Intellectual and Developmental Disabilities:
Strategies for Success (2018), available at http://www.advancingstates.org/sites/nasuad/files/2018%20MLTSS%20for%20People%20with%20IDD-
%20Strategies%20for%20Success_0.pdf (last viewed Mar. 24, 2023).
23
Center for Health Care Strategies, “Enrolling Individuals in Intellectual/Developmental Disabilities in Managed Care: A strategy for Strengthening
Long-Term Services and Supports”, March 2019, available at https://www.chcs.org/media/Integration-Strategy-3-Strengthening-LTSS-
Toolkit_032019.pdf (last view ed March 24, 2023).
24
Supra note 23.
25
The achieved savings rebate program requires plans to share savings with the state, and authorizes plans to retain statutorily-defined portions of
savings, some increments of w hich are tied to achieving AHCA-defined quality measures. S. 409.967(3)(f), F.S. STORAGE NAME: h0831b.HCA PAGE: 8
DATE: 3/28/2023
Finally, the bill requires AHCA to contract for an independent evaluation of the selected long-term care
plan to measure the plan’s performance based on specific metrics of access to care, care quality, and
cost. AHCA must submit the evaluation to the legislature by October 31, 2024.
The bill provides an effective date of July 1, 2023.
B. SECTION DIRECTORY:
Section 1: Creates s. 409.9812, F.S., related to integrated plan for persons with developmental
disabilities pilot program.
Section 2: Providing an effective date of July 1, 2023.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
The pilot program created by the bill will have an indeterminate, but likely significant, negative fiscal
impact on state expenditures. This is dependent upon the maximum number of program enrollees
authorized in the General Appropriations Act and the extent to which currently wait-listed persons
with disabilities in Miami-Dade County voluntarily enroll in the program.
Additionally, there will be an indeterminate, negative fiscal impact to AHCA for the plan evaluation
required by the bill.
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
None.
2. Expenditures:
None.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
None.
D. FISCAL COMMENTS:
PCB APC 23-01, the proposed House General Appropriations Act for Fiscal Year 2023-2024, provides
that AHCA may request budget authority associated with the enrollment of up to 600 individuals who
are currently on the HCBS waiting list at APD, and who voluntarily elect to enroll in the pilot program.
III. COMMENTS
A. CONSTITUTIONAL ISSUES:
1. Applicability of Municipality/County Mandates Provision:
Not Applicable. This bill does not appear to affect county or municipal governments.
2. Other: STORAGE NAME: h0831b.HCA PAGE: 9
DATE: 3/28/2023
None.
B. RULE-MAKING AUTHORITY:
AHCA has sufficient rule-making authority to implement the bill’s provisions.
C. DRAFTING ISSUES OR OTHER COMMENTS:
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES