This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h1517a.CFS
DATE: 3/29/2023
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/HB 1517 Agency for Persons with Disabilities
SPONSOR(S): Children, Families & Seniors Subcommittee, Plakon
TIED BILLS: IDEN./SIM. BILLS: SB 1444
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Children, Families & Seniors Subcommittee 14 Y, 0 N, As CS Guzzo Brazzell
2) Health Care Appropriations Subcommittee
3) Health & Human Services Committee
SUMMARY ANALYSIS
The Agency for Persons with Disabilities (APD) administers Florida’s individual budget-based Home and Community
Based Services (HCBS) Waiver, known as iBudget Florida (iBudget), for individuals with specified developmental
disabilities who meet Medicaid eligibility requirements. These individuals may choose to receive services in the
community through iBudget or they may choose to live in an institutional setting known as an Intermediate Care
Facility for the Developmentally Disabled (ICFDD) through traditional Medicaid administered by the Agency for
Health Care Administration (AHCA).
Adult day training (ADT) services are intended to support the participation of Medicaid recipients with developmental
disabilities in valued routines of the community, including volunteering, job exploration, accessing community
resources, and self-advocacy, in settings that are age and culturally appropriate. ADT services are a covered
service under the iBudget waiver. Currently, APD has authority to enroll ADT providers who meet minimum
education requirements and background screening requirements, but APD does not have licensure authority, so
there are no initial or continued compliance standards for client care. As a result, APD does not have the authority to
take disciplinary actions on ADT providers. A recent analysis by APD identified a significant number of issues
adversely impacting the health and safety of APD clients.
Current law authorizes APD to license comprehensive transitional education program (CTEPs), residential facilities
for individuals who have developmental disabilities or severe maladaptive behaviors, or are dually diagnosed with
mental illnesses. APD closed the state’s only CTEP in 2018 after egregious instances of abuse and neglect.
The bill modifies the process for APD to respond to applications for services, including the waiver, and ICF/DD
placement. Specifically, the bill requires APD to:
Process all applications for APD services within 60 days of receipt, regardless of the age of the applicant;
Complete eligibility determinations for waiver applicants in crisis within 45 days of receipt, or within 90 days
if APD has to request additional documentation; and
Authorize all ICFDD admissions and removes authority for APD to delegate the authority to authorize
admissions to ICFDDs.
The bill also provides authority for APD to license ADT providers and requires APD to adopt rules to create initial
and continued licensure requirements. The bill authorizes APD to take disciplinary action relating to verified findings
of abuse, neglect, or abandonment of a child or vulnerable adult and prohibits a licensee from delegating the
ultimate responsibility for the safety and care of clients in its care to others.
The bill repeals s. 393.18, F.S., effectively removing the authority for APD to license CTEPs.
The bill is expected to have a significant negative fiscal impact on state government resulting from the need of
seven full time equivalent positions for APD to implement the bill. The bill has no fiscal impact on local government.
The bill provides an effective date of October 1, 2024. STORAGE NAME: h1517a.CFS PAGE: 2
DATE: 3/29/2023
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. States can add benefits, with federal approval.
States have some flexibility in the provision of Medicaid services. A 1915(c) waiver allows states to
develop Medicaid home and community-based services to meet the needs of people who prefer to
receive long-term care services and supports in their home or community instead of in an institutional
setting.
AHCA, as the designated single state agency for Medicaid, administers the Developmental Disability
Individual Budgeting (iBudget) Waiver under a 1915(c) waiver. Through an interagency agreement,
APD is the state agency responsible for the operation of the iBudget Waiver.
Agency for Persons with Disabilities
The Agency for Persons with Disabilities (APD) provides services to persons with developmental
disabilities. A developmental disability is defined as a disorder or syndrome that is attributable to
intellectual disability, cerebral palsy, autism, spina bifida, Down syndrome, Phelan-McDermid
syndrome, or Prader-Willi syndrome; that manifests before the age of 18; and that constitutes a
substantial handicap that can reasonably be expected to continue indefinitely.
2
Community and Institutional Services
The iBudget waiver provides services in the community to individuals with developmental disabilities
who meet Medicaid eligibility requirements. Alternatively, these individuals may choose to live in an
institutional setting known as an Intermediate Care Facility for the Developmentally Disabled (ICFDD).
ICFDDs provide care and residence for individuals with developmental disabilities. ICFDDs are
licensed by AHCA.
3
Some APD clients do request services from an ICFDD instead of through the
iBudget Waiver.
4
APD is responsible for making eligibility and level of reimbursement determinations
and verifying that clients meet the level of care for institutional services. APD contracts with a vendor to
make level of reimbursement determinations.
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. 393.063(12), F.S.
3
Ch. 400, part VIII, F.S.
4
Agency for Persons with Disabilities, Agency Analysis of 2023 HB 1579.
5
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Application for APD Services
The application process for individuals wishing to receive services through the iBudget program are
detailed in s. 393.065, F.S. APD must review applications for eligibility within 45 days for children under
6 years of age and within 60 days for all other applicants.
6
Individuals who are determined to be eligible
for the Waiver program are either given a slot in the program or placed on a wait list. Currently, due to
demand exceeding available funding, individuals with developmental disabilities who wish to receive
HCBS services from APD are placed on a wait list for services in priority categories of need, unless
they are in crisis.
7
Section 393.065, F.S., requires APD to plan, develop, organize, and implement its programs of
services and treatment for persons with developmental disabilities to allow clients to live as
independently as possible. A “client” means any person already determined by APD to be eligible for
services under the iBudget Waiver. Section 393.065(2), F.S., requires APD to provide immediate
services or crisis intervention to applicants. This provision conflicts with the language in s. 393.065,
F.S., which relates to individuals who are already APD clients, not applicants. Crisis intervention
services to address immediate emergencies are available through other programs outside of APD,
including child and adult protective services.
8
Adult Day Training Providers
Adult day training (ADT) services are training services intended to support the participation of Medicaid
recipients with developmental disabilities in valued routines of the community, including volunteering,
job exploration, accessing community resources, and self-advocacy, in settings that are age and
culturally appropriate. ADT services can include meaningful day activities and training in the activities of
daily living, adaptive skills, and employment. The training, activities, and routine established by the
trainer must be meaningful to the recipient and provide an appropriate level of variation and interest.
ADT services generally are offered for individuals age 22 and above, when a recipient is out of the
public-school system.
APD currently licenses over 2,100 residential facilities statewide but does not license ADT programs.
ADT services are a covered service under the iBudget Waiver, which is operated by APD. Through the
iBudget Waiver, there are over 13,700 clients with ADT services on their cost plans. Currently, APD
has authority to enroll ADT providers who meet minimum education requirements and background
screening requirements, but they do not have licensure authority, so there are no initial or continued
compliance standards for client care. As a result, APD does not have the authority to leverage
administrative fines, sanctions, or moratoriums on ADT providers. Additionally, some ADT programs
are not enrolled iBudget Waiver providers. These settings are reimbursed via private pay arrangements
with clients and their families which precludes APD from initiating any type of disciplinary action against
such programs in response to health and safety issues (since those providers do not hold either a
license or contract with APD).
A recent analysis by APD of incident data relating to abuse, neglect, and exploitation of ADT recipients
identified a significant number of issues adversely impacting the health and safety of APD clients.
9
During the last 4 years, there have been 125 instances where DCF conducted protective services
investigations for abuse, neglect, or exploitation related to ADT services with 34 instances of verified
findings. Additionally, APD received 2,807 incident reports related to ADT services.
10
APD reviewed past incident reports occurring in ADT facilities to identify ways that such incidents could
be avoided or mitigated. Although APD cannot completely prevent incidents, APD found that that some
incidents that occurred were a result of environmental hazards not addressed through current waiver
6
S. 393.065(1), F.S.
7
S. 393.065, F.S.; See rule 65G-1.047, F.A.C., for crisis status criteria.
8
Id.
9
Agency for Persons with Disabilities, Agency Analysis of 2023 HB 1517 (on file with Children, Families & Seniors Subcommittee staff).
10
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standards for ADT services. Additionally, increased enforcement of appropriate staffing ratios could
reduce some incidents, such as elopements and client injuries. Further, required training could assist
ADTs in proper use of medical equipment and the implementation of behavioral interventions.
Comprehensive Transitional Education Programs
A comprehensive transitional education program (CTEP) is a type of residential facility authorized in
statute that serves individuals who have developmental disabilities, severe maladaptive behaviors, or a
dual diagnosis of a developmental disability and a mental illness.
11
Services provided by a CTEP must
be temporary in nature and delivered in a manner designed to achieve the primary goal of incorporating
the principles of self-determination and person-centered planning to transition individuals to the most
appropriate, least restrictive community living option of their choice.
APD closed Carlton Palms, the state’s only CTEP, in October 2018 as a result of multiple instances of
egregious abuse and neglect committed against APD clients. All 200 residents were subsequently
transferred to smaller community settings. However, current statutory language exists which would
allow for the licensure of new CTEPs. These programs render treatment in large-scale residential
settings; however, current federal requirements prohibit the provision of iBudget Waiver services in
such environments. Since most APD clients are receiving services through the iBudget Waiver
program, APD focuses on offering community-based services in smaller and more family-like settings
and does not anticipate licensing new CTEPs in the future.
Effect of the Bill
Application for APD Services
CS/HB 1517 requires APD to process all applications for services within 60 days of receipt, regardless
of the age of the applicant. The bill eliminates the requirement for APD to make eligibility
determinations within 45 days for applicants under 6 years of age.
The bill eliminates a conflict in current law that requires APD to provide immediate services or crisis
intervention to an applicant. If an applicant is seeking enrollment due to crisis, the bill requires APD to
complete an eligibility determination within 45 days after receipt of the signed application. In instances
where APD needs additional documentation to make a proper determination of an applicant’s eligibility,
the bill requires the APD to request such documentation from the applicant. If APD requests additional
documentation or provides a comprehensive assessment, the agency must then complete the eligibility
determination within 90 days after receipt of the signed application.
The bill removes the ability of APD to enter into an agreement with the Department of Elder Affairs to
conduct assessments of the level of need and medical necessity for long-term care services. As a
result, APD will have sole responsibility for determining ICFDD placement eligibility.
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S. 393.18, F.S. STORAGE NAME: h1517a.CFS PAGE: 5
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The bill also clarifies that in order for a client to receive services under the HCBS Waiver there must be
sufficient funding available within the client’s iBudget or other legislative appropriation, and the client
must:
Meet the eligibility criteria as provided under the bill, which must be confirmed by the agency;
Be eligible for the state Medicaid program under Title XIX of the Social Security Act or the
Supplemental Security Income program;
Meet the level of care requirements for an intermediate 191 care facility for individuals with
intellectual disabilities pursuant to 42 C.F.R. s. 435.217(b)(1) and 42 C.F.R. s. 440.150; and
Meet the requirements set forth in the approved federal waiver authorized under s. 1915(c) of
the Social Security Act and 42 C.F.R. s. 441.302.
Adult Day Training Providers
The bill provides authority for APD to license ADT providers and requires APD to adopt rules to create
initial and continued licensure requirements relating to:
Training to detect, prevent, and report sexual abuse, abuse, neglect, exploitation, and
abandonment;
Proof of financial ability to operate;
Quality and adequacy of client care;
Incident reporting;
Uniform fire safety standards; and
The preparation and annual update of a comprehensive emergency management plan.
The bill authorizes APD to take disciplinary action relating to verified findings of abuse, neglect, or
abandonment of a child or vulnerable adult and prohibits a licensee from delegating the ultimate
responsibility for the safety and care of clients in its care to others. Further, this bill clarifies that APD’s
ability to impose disciplinary actions is not necessarily negated by a licensee’s remedial action.
When considering an application for the licensure of an ADT or residential facility, APD may deny an
application if it is determined that there is evidence that the applicant is unqualified due to lack of good
moral character. “Good moral character” includes a personal history of honest, fairness, and respect for
the rights of others and the laws of the state and nation.
Comprehensive Transitional Education Programs
The bill removes obsolete language regarding Comprehensive Transitional Education Programs that no
longer operate within the state. This will prohibit the licensure of any future facilities.
The bill provides an effective date of October 1, 2024.
B. SECTION DIRECTORY:
Section 1: Amends s. 393.063, F.S. relating to definitions.
Section 2: Amends s. 393.065, F.S., relating to application and eligibility determination.
Section 3: Amends s. 393.0655, F.S., relating to screening of direct service providers.
Section 4: Amends s. 393.067, F.S., relating to facility licensure.
Section 5: Amends s. 393.0673, F.S., relating to denial, suspension, or revocation of license;
moratorium on admissions; administrative fines; procedures.
Section 6: Amends s. 393.0678, F.S., relating to receivership proceedings.
Section 7: Amends s. 393.135, F.S., relating to sexual misconduct prohibited; reporting required;
penalties.
Section 8: Repeals s. 393.18, F.S., relating to comprehensive transitional education program. STORAGE NAME: h1517a.CFS PAGE: 6
DATE: 3/29/2023
Section 9: Amends s. 394.875, F.S., relating to crisis stabilization units, residential treatment facilities,
and residential treatment centers for children and adolescents; authorized services; license
required.
Section 10: Amends s. 383.141, F.S., relating to prenatally diagnosed conditions; patient to be
provided information; definitions; information clearinghouse; advisory council.
Section 11: Amends s. 400.063, F.S., relating to resident protection.
Section 12: Amends s. 1002.394, F.S., relating to The Family Empowerment Scholarship Program.
Section 13: Provides an effective date of October 1, 2024.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
The bill is expected to have a significant negative fiscal impact on state government resulting from
the need of seven full time equivalent positions at a total cost of $457,616 in recurring funding for
APD to implement the bill’s requirements to begin licensing ADT’s.
12
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. This 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 APD to implement the provisions of the bill.
C. DRAFTING ISSUES OR OTHER COMMENTS:
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DATE: 3/29/2023
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES
On March 27, 2023, the Children, Families & Seniors Subcommittee adopted an amendment and reported
the bill favorably as a committee substitute. The amendment included requirements for APD to:
Process all iBudget Waiver applications within 60 days of receipt, regardless of the age of the
applicant;
Complete eligibility determinations for iBudget Waiver applicants in crisis within 45 days of receipt
or within 90 days if APD has to request additional documentation; and
Authorize all ICFDD admissions and removed authority for APD to delegate the authority to
authorize admissions to ICFDDs.
This analysis is drafted to the committee substitute as passed by the Children, Families & Seniors
Subcommittee.