The Florida Senate
BILL ANALYSIS AND FISCAL IMPACT STATEMENT
(This document is based on the provisions contained in the legislation as of the latest date listed below.)
Prepared By: The Professional Staff of the Appropriations Committee on Health and Human Services
BILL: CS/SB 452
INTRODUCER: Appropriations Committee on Health and Human Services and Senator Harrell
SUBJECT: Home Health Aides for Medically Fragile Children
DATE: March 9, 2023
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Looke Brown HP Favorable
2. McKnight Money AHS Fav/CS
3. FP
Please see Section IX. for Additional Information:
COMMITTEE SUBSTITUTE - Substantial Changes
I. Summary:
CS/SB 452 creates the Home Health Aides for Medically Fragile Children program to help
ameliorate the impact of the shortage of health care workers on medically fragile children. The
bill requires the Agency for Health Care Administration (AHCA), in consultation with the Board
of Nursing (BON), to approve any training program created by a Home Health Agency (HHA)
that meets the federal standards
1
for a nurse aide training program and which is meant to train
family caregivers as home health aides for medically fragile children (aide).
The bill requires that such a program consist of at least 85 hours of training in specified topics
and allows a HHA to employ a family caregiver as an aide if he or she has completed the training
program and met other specified criteria, including background screening. The bill also requires
an aide to complete HIV/AIDS and Cardiopulmonary Resuscitation (CPR) training and requires
the employing HHA to ensure that the aide has 12 hours of in-service training every 12 months.
The bill grants civil immunity to a HHA that terminates or denies employment to an aide who
fails to maintain the requirements of the section or whose name appears on a criminal screening
report.
The bill allows the AHCA, in consultation with the BON, to adopt rules to implement the bill
and requires the AHCA to assess the program annually and to modify the Medicaid state plan
and implement any federal waivers necessary to implement the program.
1
42 C.F.R. 483.151-483.154 and 484.80
REVISED: BILL: CS/SB 452 Page 2
The bill authorizes four full-time equivalent (FTE) positions with associated salary rate of
186,483, and $353,589 in recurring funds and $118,728 in nonrecurring funds from the Health
Care Trust Fund in Fiscal Year 2023-2024 to the AHCA to implement provisions of the bill.
The bill has an indeterminate, significant negative fiscal impact on the Florida Medicaid
program. See Section V of this analysis.
The bill takes effect upon becoming law.
II. Present Situation:
Home Health Agencies
A “home health agency” (HHA) is an organization that provides home health services.
2
Home
health services comprise health and medical services and supplies furnished to an individual in
the individual’s home or place of residence.
3
Home health aides
4
and certified nursing assistants
5
(CNAs) are unlicensed health care workers
employed by a HHA to provide personal care
6
to patients and assist them with the following
activities of daily living:
Ambulation;
Bathing;
Dressing;
Eating;
Personal hygiene;
Toileting;
Physical transferring;
Assistance with self-administered medication; and
Administering medications.
7
2
s. 400.462(12), F.S.
3
s. 400.462(15), F.S., home health services include the following: nursing care; physical, occupational, respiratory, or speech
therapy; home health aide services; dietetics and nutrition practice and nutrition counseling; and medical supplies, restricted
to drugs and biologics prescribed by a physician.
4
s. 400.462(14), F.S., a home health aide is a person who is trained or qualified, as provided by rule, and who provides
hands-on personal care, performs simple procedures as an extension of therapy or nursing services, assists in ambulation or
exercises, assists in administering medications as permitted in rule and for which the person has received training established
by the agency, or performs tasks delegated to him or her under ch. 464, F.S.
5
s. 464.201(3), F.S., a CNA is a person who meets the qualifications of part II of ch. 464, F.S., and who is certified by the
Board of Nursing as a certified nursing assistant.
6
s. 400.462(23), F.S., defines “personal care” as assistance to a patient in the activities of daily living, such as dressing,
bathing, eating, or personal hygiene, and assistance in physical transfer, ambulation, and in administering medications as
permitted by rule.
7
Rule 59A-8.002(3), F.A.C. BILL: CS/SB 452 Page 3
Florida’s Medicaid Model Waiver
Florida’s Model Waiver is an existing waiver designed to delay or prevent institutionalization
and allow recipients to maintain stable health while living at home or in their community. The
waiver’s purpose is to provide medically necessary services to eligible children under 21 years of
age who have degenerative spinocerebellar disease and are living at home or in their community
or who are medically fragile and have resided in a skilled nursing facility for at least 60
consecutive days prior to entrance on the waiver. For the purposes of the waiver, “Medically
Fragile” is defined as an individual who is medically complex and technologically dependent on
medical apparatus or procedures to sustain life, or is dependent on a heightened level of medical
supervision to sustain life, and without such services is likely to expire without warning.
The Model Waiver provides the following services to eligible recipients:
Respite care;
Environmental accessibility adaptations; and
Transition Case Management.
The Model Waiver has a maximum capacity of 20 recipients and a reserved capacity for 15
children transitioning into the community from a skilled nursing facility.
8
Private Duty Nursing Services
Currently, federal law allows Medicaid to reimburse for private duty nursing (PDN) services. 42
C.F.R. 440.80 defines PDN services as nursing services for beneficiaries who require more
individual and continuous care than is available from a visiting nurse or routinely provided by
the nursing staff of the hospital or skilled nursing facility. These services are provided:
By a registered nurse or a licensed practical nurse;
Under the direction of the beneficiary’s physician; and
To a beneficiary in one or more of the following locations at the option of the state:
o His or her own home;
o A hospital; or
o A skilled nursing facility
Florida Medicaid allows PDN to be provided to recipients under the age of 21 years who require
such services, and PDN can be provided by a HHA, a licensed practical nurse (LPN), or a
registered nurse (RN).
9, 10
If the PDN is provided by a parent or legal guardian of the recipient,
Medicaid will reimburse for up to 40 hours per week, per recipient, so long as the parent or
guardian has a valid LPN or RN license and is employed by a HHA.
11
However, other than those
mentioned above, services furnished by relatives as defined in s. 429.02(18), F.S., household
8
Application for a §1915(c) Home and Community Based Services Waiver, Florida Agency for Health Care Administration,
Jul. 1, 2020, available at https://ahca.myflorida.com/medicaid/hcbs_waivers/docs/Model_Waiver_Document_2020.pdf (last
visited Feb. 16, 2023).
9
59G-4.261, F.A.C.
10
Florida Medicaid, Private Duty Nursing Services Coverage Policy, Agency for Health Care Administration, Nov. 2016
available at https://ahca.myflorida.com/medicaid/review/Specific/59G-4-
261_Private_Duty_Nursing_Services_Coverage_Policy.pdf (last visited Feb. 16, 2023).
11
Id. BILL: CS/SB 452 Page 4
members, or any person with custodial or legal responsibility for the recipient are specifically not
covered under the PDN policy.
12
Family Caregiver Programs in Other States
Currently, five states have family caregiver programs: Arizona, Colorado, New Hampshire,
Pennsylvania, and Indiana.
13
Although each state has different specific criteria, the criteria are all
similar in that the eligible relative must be under 21 years of age, qualify for the state’s Medicaid
program, and be medically fragile or medically complex. Each state also requires the caregiver to
be trained and/or licensed as a CNA or that state’s equivalent. Once the caregiver has achieved
his or her training or licensure, he or she is required to obtain employment with a HHA and, at
that point, is eligible to be compensated by the state’s Medicaid program for services they render
to their family member.
14
III. Effect of Proposed Changes:
Section 1 creates s. 400.4765, F.S., to establish the Home Health Aides for Medically Fragile
Children program. The bill amends s. 400.462, F.S., to define the following terms:
“Approved Training Program” to mean “a course of training approved by the Agency for
Health Care Administration (AHCA), in consultation with the Board of Nursing (BON),
under s. 400.4765, F.S., to train family caregivers as home health aides for medically fragile
children.”
“Eligible Relative” to mean “with respect to the home health aide for medically fragile
children program under s. 400.4765, F.S., a person 21 years of age or younger who is eligible
to receive continuous skilled nursing or skilled nursing respite care services under the
Medicaid program and is a relative of a home health aide for medically fragile children.”
“Family Caregiver” to mean “a person providing or intending to provide significant personal
care and assistance to an eligible relative 21 years of age or younger who has an underlying
physical or cognitive condition that prevents him or her from safely living independently.”
“Home Health Aide for Medically Fragile Children” to mean “a family caregiver who meets
the qualifications specified in s. 400.4765, F.S.; performs tasks delegated to him or her under
chapter 464, F.S., while caring for an eligible relative; and provides care and assistance to an
eligible relative relating to:
o Activities of daily living, such as those associated with personal care, maintaining
mobility, nutrition and hydration, toileting and elimination, assistive devices, and safety
and cleanliness.
o Data gathering.
o Reporting abnormal signs and symptoms.
o Patient socialization and reality orientation.
o Cardiopulmonary resuscitation and emergency care.
o Residents’ or patients’ rights.
o Documentation of services.
12
Id.
13
Team Select Home Care, Program Locations, available at https://tshc.com/states-where-the-program-is-available/ (last
visited Feb. 20, 2023).
14
Team Select Home Care, Program Locations, available at https://tshc.com/states-where-the-program-is-available/ (last
visited Feb. 20, 2023).3 BILL: CS/SB 452 Page 5
o End-of-life care.
o Postmortem care.”
Section 2 authorizes Home Health Aides for Medically Fragile Children (aides) to perform
certain tasks delegated by a registered nurse, including medication administration, and requires
licensed Home Health Agencies (HHAs) to ensure that aides providing such services are
adequately trained to perform these tasks.
Section 3 requires HHAs to ensure that each aide employed by or under contract with the HHA
is adequately trained to perform the tasks of a home health aide in the home setting and prohibits
a HHA from requiring an aide to repay or reimburse the HHA for costs associated with the
training program established under the bill.
Section 4 requires the AHCA, in consultation with the BON, to approve a training program
created by a HHA that meets federal requirements
15
and that will train family caregivers as aides
to provide trained nursing services to eligible relatives. The training program must require a
family caregiver to complete 85 hours of training, including, but not limited to:
A minimum of 40 hours of theoretical instruction, offered in various formats and times of
day, in nursing, including, but not limited to, instruction on all of the following:
o Person-centered care.
o Communication and interpersonal skills.
o Infection control.
o Safety and emergency procedures.
o Assistance with activities of daily living.
o Mental health and social service needs.
o Care of cognitively impaired individuals.
o Basic restorative care and rehabilitation.
o Patient rights and confidentiality of personal information and medical records.
o Relevant legal and ethical issues.
A minimum of 20 hours of skills training on basic nursing skills, including, but not limited
to:
o Hygiene, grooming, and toileting.
o Skin care and pressure sore prevention.
o Nutrition and hydration.
o Measuring vital signs, height, and weight.
o Safe lifting, positioning, and moving of patients.
o Wound care.
o Portable oxygen use and safety and other respiratory procedures.
o Tracheostomy care.
o Enteral care and therapy.
o Peripheral intravenous assistive activities and alternative feeding methods.
o Urinary catheterization and ostomy care.
At least 16 hours of clinical training under direct supervision of a licensed registered nurse.
15
42 C.F.R. 483.151-483.154 and 484.80 BILL: CS/SB 452 Page 6
The bill exempts family caregivers who have graduated from an accredited nursing school but
have not yet taken the state licensure exam from the requirement to take the training.
In addition to the required training, a family caregiver must care for an eligible relative;
demonstrate a minimum competency to read and write; pass a background screening pursuant to
s. 400.512, F.S., except that the AHCA must waive this requirement if the family caregiver has
passed a background screening pursuant to ss. 400.512 or 400.809, F.S., within the previous 90
days and the caregiver’s results are not retained in the Care Provider Background Screening
Clearinghouse.
16
If a family caregiver allows 24 consecutive months to pass without performing any nursing-
related services for an eligible relative, the family caregiver must recomplete the training
program prior to serving as an aide.
After becoming an aide, he or she must complete an HIV/AIDS training course and maintain a
certificate in cardiopulmonary resuscitation (CPR). Additionally, the HHA employing the aide
must ensure that he or she completes 12 hours of in-service training during each 12-month period
as a condition of employment. The bill specifies that the HIV/AIDS training may count toward
the 12 hours of training and that the HHA must maintain documentation demonstrating
compliance with this requirement.
The bill grants civil immunity to a HHA for terminating or denying employment to an aide who
fails to maintain the requirements of the bill or whose name appears on a criminal screening
report of the Florida Department of Law Enforcement. The bill also grants immunity from a
cause of action and monetary liability to any licensed facility or the facility’s governing board,
medical staff, disciplinary board, agents, investigators, witnesses, employees, or any other person
for any action taken in good faith to comply with the section.
The bill also specifies that a HHA, or its agent, may not use criminal records or juvenile records
relating to vulnerable adults for any purpose other than determining if the person meets the
requirements of the section and that the HHA must maintain the confidentiality of any such
records or information it obtains that is confidential and exempt from public records laws.
Sections 5 and 6 amend several sections of law to include aides along with certified nursing
assistants and home health aides in allowing tasks to be delegated to the aide, including the
administration of medication, and requiring that a HHA ensure that any tasks delegated to the
aide meet state law requirements and that the aide is properly trained.
Section 7 requires the AHCA to conduct an annual assessment of the program. The assessment
must include caregiver satisfaction with the program, identify additional supports that may be
needed by aides, and assess the rate and extent of hospitalization of children who are attended by
aides compared to those in home health services without such an aide. The AHCA must report its
findings to the Governor and the Legislature by January 1 of each year beginning in 2025.
16
Created pursuant to s. 435.12, F.S. BILL: CS/SB 452 Page 7
Section 8 requires the AHCA to modify the Medicaid state plan and implement any federal
waivers necessary to implement the program. The AHCA is required to establish a Medicaid fee
schedule for HHAs employing aides at $25 per hour with no more than 8 hours per day.
Sections 9 and 10 make several cross-reference changes to conform to the changes made in the
bill.
Section 11 authorizes four full-time equivalent (FTE) positions with associated salary rate of
186,483, and $353,589 in recurring funds and $118,728 in nonrecurring funds from the Health
Care Trust Fund in Fiscal Year 2023-2024 to the AHCA to implement provisions of the bill.
Section 12 provides that the act is effective upon becoming law.
IV. Constitutional Issues:
A. Municipality/County Mandates Restrictions:
None.
B. Public Records/Open Meetings Issues:
None.
C. Trust Funds Restrictions:
None.
D. State Tax or Fee Increases:
None.
V. Fiscal Impact Statement:
A. Tax/Fee Issues:
None.
B. Private Sector Impact:
CS/SB 452 may have an indeterminate, positive fiscal impact on family caregivers who
are trained as Home Health Aides for Medically Fragile Children (aides) and reimbursed
for time spent caring for a family member under the bill.
The bill prohibits a Home Health Agency (HHA) from requiring an aide to repay or
reimburse the HHA for costs associated with the training program. Therefore, any costs
associated with providing the required training under the bill will be absorbed by a HHA.
BILL: CS/SB 452 Page 8
The cost for a level 2 background screening with five years of fingerprint retention within
the Care Provider Background Screening Clearinghouse is $61.25.
17
The number of
individuals impacted by this requirement is indeterminate.
C. Government Sector Impact:
18
The bill may have a significant negative fiscal impact on the Florida Medicaid program in
order to reimburse family caregivers who become trained as aides. The extent of the
impact is indeterminate and will depend on the number of eligible family caregivers who
qualify as an aide and provide services.
The bill requires the Agency for Health Care Administration (AHCA) to establish a
Medicaid fee schedule for HHAs employing aides at $25 per hour with no more than
eight hours per day per provider. Current Medicaid fee schedules for applicable services
as specified in the AHCA’s promulgated fee schedules are $18.04 per visit for skilled
nursing services and $17.32 per hour for personal care services, which is approximately
44.34 percent less than the proposed reimbursement rate. As these services are provided
on a “per visit” basis and not hourly, it is difficult to predict the exact impact of
establishing a new rate methodology for services provided by aides. Further, although
Florida Medicaid establishes fee schedules for home health services provided through the
Fee-For-Service delivery system, health plans participating in Florida’s Statewide
Medicaid Manage Care Program do not have to pay the AHCA established rates and may
negotiate mutually agreed-upon rates with HHA providers, unless specified in Federal
and/or State law, or in their contract with the AHCA.
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.
The table below highlights the potential cost increase to the Florida Medicaid program
based on a projected rate of participation for eligible relatives as outlined in the bill:
17
Florida Department of Law Enforcement, SB 452 Bill Analysis (Feb. 17, 2023) (on file with the Senate Appropriations
Committee on Health and Human Services).
18
Agency for Health Care Administration, SB 452 Bill Analysis (Mar. 1, 2023) (on file with the Senate Appropriations
Committee on Health and Human Services). BILL: CS/SB 452 Page 9
Florida Medicaid Program Potential Fiscal Impact
Rate of
Participation
2,080 hours or 40
hours per week
2,219 hours
(number of hours
claimed in FY21-22)
2,920 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 AHCA has also identified the following fiscal impacts in order to meet the requirements
outlined in the bill:
Training Program
One (1) full-time equivalent (FTE) Senior Management Analyst Supervisor – Selected
Exempt Service (SES) to implement and oversee reviews of training program submissions,
manage stakeholder input, and develop rules.
Two (2) FTE Registered Nurse Consultants to review training programs for compliance with
state and federal requirements and manage provider inquiries.
Annual Assessment
An estimated cost of $150,000 in contract services to develop a data collection tool or modify
an existing AHCA system to collect the information and an additional recurring $50,000 for
system maintenance and enhancement.
One (1) FTE Medical Health Care Program Analyst to analyze the results of the data.
Direct Care Workforce Survey
The bill amends the direct care workforce survey in section 408.822, F.S., to include aides
and requires additional reporting requirements for these caregivers. The AHCA is already
working on implementation of the survey and will leverage existing resources to address any
changes needed.
Further, changes in the bill would require the AHCA to update rules, as well as the Florida
Medicaid Management Information System (FLMMIS). The AHCA may also need to update the
Medicaid state plan and/or its waivers to sure the State has proper federal authority to allow
Medicaid reimbursement for family caregivers. These actions are part of the Florida Medicaid
program’s routine business practices and can be accomplished using existing resources.
The AHCA estimates that implementation of SB 452 will result in non-recurring expenditures of
$ 472,317 in year 1, and recurring expenditures of $353,589 in years 2 and 3. BILL: CS/SB 452 Page 10
VI. Technical Deficiencies:
None.
VII. Related Issues:
None.
VIII. Statutes Affected:
This bill substantially amends the following sections of the Florida Statutes: 400.462, 400.464,
400.476, 400.489, 400.490, 768.38, and 768.381.
This bill creates the following sections of the Florida Statutes: 400.4765 and 400.54.
IX. Additional Information:
A. Committee Substitute – Statement of Substantial Changes:
(Summarizing differences between the Committee Substitute and the prior version of the bill.)
CS by Appropriations Committee on Health and Human Services on March 8, 2023:
The committee substitute:
Makes a technical correction to the statutory cross-reference for background
screenings.
Authorizes positions and an appropriation.
B. Amendments:
None.
This Senate Bill Analysis does not reflect the intent or official position of the bill’s introducer or the Florida Senate.