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 Committee on Fiscal Policy
BILL: CS/CS/SB 1084
INTRODUCER: Fiscal Policy Committee; Appropriations Committee on Health and Human Services and
Senator Trumbull
SUBJECT: Pilot Program for Individuals with Developmental Disabilities
DATE: April 26, 2023
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Brown Brown HP Favorable
2. Gerbrandt Money AHS Fav/CS
3. Brown Yeatman FP Fav/CS
Please see Section IX. for Additional Information:
COMMITTEE SUBSTITUTE - Substantial Changes
I. Summary:
CS/CS/SB 1084 creates s. 409.9855, F.S., to establish a Medicaid long-term care managed care
pilot program in certain counties to integrate health care services, long-term care services, and
home and community-based services for persons with developmental disabilities. The pilot
program will be available, on a volunteer basis, to Medicaid eligible individuals on the iBudget
waitlist.
The bill is likely to have a significant negative fiscal impact. Neither the Agency for Health Care
Administration (AHCA), which operates the state’s Medicaid program, nor the Agency for
Persons with Disabilities, which administers the iBudget Wavier, have submitted an estimate of
the bill’s potential fiscal impact. See Section V. of this analysis.
The bill takes effect upon becoming a law.
II. Present Situation:
The Florida Medicaid Program
Florida Medicaid is the health care safety net for low-income Floridians. The national Medicaid
program is a partnership of federal and state governments established to provide coverage for
REVISED: BILL: CS/CS/SB 1084 Page 2
health services for eligible persons. Florida’s program is financed through state and federal
funds.
1
The Agency for Health Care Administration (AHCA) is the single state agency responsible for
the administration of the Florida Medicaid program, authorized under Title XIX of the Social
Security Act (SSA).
2
This authority includes establishing and maintaining a Medicaid state plan
approved by the federal Centers for Medicare & Medicaid Services (CMS) and maintaining any
Medicaid waivers needed to operate the Florida Medicaid program as directed by Florida
Statute,
3
the General Appropriations Act (GAA), and other legislation accompanying the GAA.
A Medicaid state plan is an agreement between a state and the federal government describing
how that state administers its Medicaid programs. The state plan establishes groups of
individuals covered under the Medicaid program, services that are provided, payment
methodologies, and other administrative and organizational requirements. State Medicaid
programs may request from CMS a formal waiver of the requirements codified in the SSA,
which provides states flexibility in providing services not afforded through their Medicaid state
plan.
Statewide Medicaid Managed Care
In Florida, a large majority of Medicaid recipients receive their services through a managed care
plan contracted with the AHCA under the Statewide Medicaid Managed Care (SMMC)
program.
4
Other recipients who are not eligible for managed care, are not subject to mandatory
managed care enrollment, or are not yet enrolled in a plan, are provided services directly from
health care practitioners or facilities, and in those cases, providers are paid on a fee-for-service
basis.
SMMC has three components:
Managed Medical Assistance (MMA), under which the AHCA makes payments for primary
and acute medical treatments and related services using a managed care model;
Long-term Care Managed Care (LTCMC), under which the AHCA makes payments for
long-term care, including home and community-based services, using a managed care model;
and
The Medicaid Prepaid Dental Health Program (Prepaid Dental), under which the AHCA
makes payments for dental services for children and adults using a managed care model.
SMMC benefits are authorized through federal waivers and are specifically required by the
Florida Legislature in ss. 409.973 and 409.98, F.S. SMMC benefits cover primary, acute,
preventive, behavioral health, prescribed drugs, long-term care, and dental services. Section
409.973, F.S., specifies the minimum services that must be provided by managed care plans:
1
Section 20.42, F.S.
2
Section 409.963, F.S.
3
See parts III and IV of ch. 409, F.S.
4
As of January 31, 2023, Florida Medicaid’s total enrollment comprised 5,696,638 persons. Eighty-seven percent were
enrolled in a Medicaid managed care plan. See:
https://ahca.myflorida.com/medicaid/Finance/data_analytics/enrollment_report/docs/ENR_202301.xls (last visited March 9,
2023). BILL: CS/CS/SB 1084 Page 3
Managed Care Plan Benefits
5
Advanced practice registered nurse services Medical supplies, equipment, prostheses, and
orthoses
Ambulatory surgical treatment center services Mental health services
Birthing center services Nursing care
Chiropractic services Optical services and supplies
Donor human milk bank services Optometrist services
Early periodic screening diagnosis and
treatment services for recipients under age 21
Physical, occupational, respiratory, and
speech therapy services
Emergency services Physician services, including physician
assistant services
Family planning services and supplies.
Pursuant to 42 C.F.R. s. 438.102, plans may
elect to not provide these services due to an
objection on moral or religious grounds, and
must notify the agency of that election when
submitting a reply to an invitation to negotiate
Podiatric services
Healthy start services, except as provided in s.
409.975(4)
Prescription drugs
Hearing services Renal dialysis services
Home health agency services Respiratory equipment and supplies
Hospice services Rural health clinic services
Hospital inpatient services Substance abuse treatment services
Hospital outpatient services Transportation to access covered services
Laboratory and imaging services
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:
6
More than 5.5 million low-income individuals, including approximately 2.5 million children,
or 54 percent of the children in Florida;
More than 54 percent of the births occurring in Florida in calendar year 2020; and
More than 60 percent of the nursing home days in Florida.
Types of Comprehensive Medicaid Managed Care Plans
Comprehensive services in SMMC are managed by two types of managed care plans: traditional
managed care organizations and provider service networks (PSNs). Traditional managed care
organizations are usually health insurers or health maintenance organizations (HMOs). PSNs are
managed care plans that are owned or are majority-controlled by health care providers, such as
physician groups or hospitals.
5
Section 409.973, F.S.
6
Agency for Health Care Administration, Presentation to the Senate Health Policy Committee, Jan. 23, 2023. BILL: CS/CS/SB 1084 Page 4
All managed care plans in SMMC, including PSNs, are reimbursed as prepaid plans. That is,
they are paid capitated rates (prospective, per-member, per-month payments) by the AHCA in
advance for any particular month and are expected to provide medically necessary services to
their respective members during that month, using the dollars within that month’s capitation.
Medically necessary services are required to be provided regardless of whether the capitation
includes all the dollars necessary to provide those services.
7
The 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. That is,
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.
The AHCA began the next procurement process in 2022 for implementation in the 2025 plan
year and released the re-procurement solicitation documents on April 11, 2023.
8
Medicaid 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 federal waivers 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. The Medicaid Long-term Care Waiver provides services to eligible individuals
age 18 or older who need long-term services and supports, including individuals over the age of
18 with a diagnosis of cystic fibrosis, AIDS, or a traumatic brain or spinal cord injury. The Long-
term Care Waiver is designed to delay or prevent institutionalization and allow waiver recipients
to maintain stable health while receiving services at home and in the community. Individuals in
the program may also be served in a nursing facility setting. The Long-Term Care Waiver is a
capitated, managed care program.
Section 409.98, F.S., specifies the non-institutional, often non-acute, long-term care benefits that
must be provided by the long-term care managed care program:
7
See s. 409.968(1) and (2), F.S.
8
Agency for Health Care Administration, Presentation to the Senate Health Policy Committee, Jan. 23, 2023. BILL: CS/CS/SB 1084 Page 5
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 Nursing Facility Care Services
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 services that will not cure or mitigate a
medical diagnosis. 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) can be provided to
assist people with developmental disabilities with activities of daily living which enables them to
live in their homes or communities, rather than moving to a facility for care.
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.
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 with the stated
purpose of:
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 waiver retains the Medicaid requirement that enrollees be low-income, but measures only the developmentally
disabled person’s income; not the income generated by the whole household.
11
Section 393.063(12), F.S. BILL: CS/CS/SB 1084 Page 6
Promoting and maintaining the health and welfare of eligible individuals with developmental
disabilities.
Providing medically necessary supports and services to delay or prevent institutionalization.
Fostering the principles of self-determination as a foundation for services and supports.
12
Section 393.066 (3), F.S., specifies that community-based services offered through the iBudget
must include the following medically necessary services to prevent institutionalization:
Home and Community-Based Services
13
Adult Day Training Respite Services
Family Care Services Social Services
Guardian Advocate Referral Services Physical, Occupational, Respiratory, and
Speech Therapy
Medical/Dental Services Supported Employment
Parent Training Supported Living
Personal Care Services Behavioral Services
Recreation Transportations
Residential Facility Services Residential Habilitation
Under the broad service categories specified in s. 393.066(3), F.S., the APD offers 26 supports
and services delivered by contracted service providers to assist individuals to live in their own
homes or the community.
14
These 26 services include:
Adult day training.
Behavioral analysis services.
Behavior assistant services.
Companion services.
Consumable medical supplies.
Dietician services.
Durable medical equipment and supplies.
Environmental accessibility and adaptations.
Occupational therapy.
Personal emergency response systems.
Personal supports.
Physical therapy.
Prevocational service.
Private duty nursing.
Residential habilitation, including the following levels:
o Standard level.
o Behavior-focused level.
o Intensive-behavior level.
o Enhanced-intensive-behavior level.
12
Agency for Health Care Administration, Developmental Disabilities Individual Budgeting Waiver Services Coverage and
Limitations Handbook, September 2021.
13
Section 393.006(3), F.S.
14
Supra, note 11. BILL: CS/CS/SB 1084 Page 7
Residential nursing services.
Respiratory therapy.
Respite Care.
Skilled Nursing.
Specialized medical home care.
Specialized mental health counseling.
Speech therapy.
Support coordination.
Supported employment.
Supported living coaching.
Transportation.
15
Currently, HCBS services are not integrated with Medicaid acute medical services, as those
services are administered for iBudget enrollees by the AHCA, usually through the fee-for service
model, not through SMMC. However, every iBudget enrollee receives case management services
from a waiver support coordinator. Waiver support coordinators are responsible for identifying,
coordinating, and accessing supports and services from all available funding sources for iBudget
enrollees, including Medicaid state plan services.
Florida law requires that Medicaid be the payer of last resort for medically necessary supports
and services,
16
and that iBudget enrollees use all available services authorized under the
Medicaid state plan, school-based services, private insurance and other benefits, prior to using
iBudget Waiver funds.
17
Therefore waiver support coordinators must first obtain supports and
services from third party payers, other government or community programs, school-based
programs, and natural supports.
Historically, despite the utilization management tools authorized by law and the entitlement
flexibilities provided by the federal waiver, APD has frequently been unable to manage the
iBudget program within the budget appropriated by the legislature, resulting in significant
deficits
18
and surpluses.
19
In 2019, the Legislature directed the APD to implement better monitoring and accounting
procedures and to take corrective action when deficits are projected to develop. Additionally,
APD was required to develop a plan to redesign the iBudget program if a deficit were to reoccur
15
All providers must be in compliance with the provider qualifications as stated in the Florida Medicaid Developmental
Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook, September 2021, incorporated by
reference in rule 59G-13.070, F.A.C. The handbook is available on the Agency for Health Care Administration’s Web site at:
http://ahca.myflorida.com/Medicaid/review/index.shtml, and at http://www.flrules.org/Gateway/reference.asp?No=Ref-
13442 (last visited April 17, 2023).
16
Section 409.910, F.S.
17
393.0662(3), F.S.
18
For example, the legislature made retroactive general revenue appropriations to address APD deficits that occurred in
Fiscal Year’s 2017-2018 ($22.0 million), 2018-2019 ($41.2 million), and 2019-2020 ($50.8 million). See, the Fiscal Year
2019-2020 General Appropriations Act, section 30 and the Fiscal Year 2020-2021 General Appropriations Act, sections 29
and 30, respectively.
19
The APD’s historical deficits have been offset by more recent general revenue surpluses of $11.3 million, $1.0 million and
$39.6 million in Fiscal Year’s 2019-2020, 2020-2021, and 2021-2022, respectively. Data was retrieved from the Legislative
Budgeting System. BILL: CS/CS/SB 1084 Page 8
in the 2018-2019 fiscal year.
20
The APD did generate a deficit that year and submitted a plan to
address the budget shortfall that included the following recommendations:
Include the iBudget Waiver in the Social Services Estimating Conference;
Implement a behavioral health Intermediate Care Facility service rate;
Implement individual caps for iBudget clients;
Implement budget transfers from the Medicaid state plan to the iBudget waiver for clients
turning 21;
Expand the Medicaid Assistive Care Services program to include APD group homes;
Centralize the significant additional needs process;
Implement service limitations on Life Skills Development services; and
Restructure support coordination services.
21
In 2020, Senate Bill 82 was passed and addressed some of the recommendations from the APD’s
iBudget waiver redesign plan, specifically the bill:
Centralized the significant additional needs process at APD headquarters; and
Restructured support coordination services.
22
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.
23
Currently, the program serves over 35,300
enrolled people.
24
iBudget Waiver Waitlist
The APD maintains a waitlist of people who would like to enroll in the iBudget. 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.
25
As new funding becomes available, APD enrolls people from the waitlist in a statutory order of
priority in seven categories:
26
Category 1 – Clients deemed to be in crisis.
Category 2 – Specified children from the child welfare system.
27
20
Chapter 2019-116, s. 26, Laws of Fla.
21
Agency for Persons with Disabilities and Agency for Health Care Administration, 2019 iBudget Waiver Redesign, Sept.
30, 2019.
22
Chapter 2020-71, Laws of Florida
23
Chapter 2022-156, Laws of Fla., Specific Appropriation 245.
24
Agency for Persons with Disabilities, Quarterly Report on Agency Services to Floridians with 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).
25
Agency for Persons with Disabilities, Quarterly Report on Agency Services to Floridians with 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).
26
Section 393.065(5), F.S.
27
See s. 393.065(5)(b), F.S., for specific criteria. BILL: CS/CS/SB 1084 Page 9
Category 3 – Includes, but is not limited to, clients:
o 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;
o Who are at substantial risk of incarceration or court commitment without supports;
o 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
o 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.
Category 4 – Includes, but is not limited to, clients whose caregivers are 70 years of age or
older and for whom a caregiver is required but no alternate caregiver is available;
Category 5 – Includes, but is not limited to, clients who are expected to graduate within the
next 12 months from secondary school and need support to obtain or maintain competitive
employment, or to pursue an accredited program of postsecondary education to which they
have been accepted.
Category 6 – Clients 21 years of age or older who do not meet the criteria for categories 1-5.
Category 7 – Clients younger than 21 years of age who do not meet the criteria for categories
1-4.
28
APD rarely moves beyond Category 1 (individuals experiencing a crisis) 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 enrollees.
29
Medicaid Coverage for iBudget Enrollees
iBudget waiver benefits include Medicaid coverage for medical services, administered by the
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 to
provide their care. However, under current law, using the managed care model is an option for
iBudget enrollees – not a requirement. iBudget participants may opt to use the traditional fee-for-
service model of service delivery.
30
Medical services and HCBS are currently not integrated because they are provided by two
different programs in two different state agencies.
28
Section 393.065(5), F.S.
29
Of the 2,646 new enrollees, 182 were in Category 2 (children aging out of the child welfare system); the remainder were in
special categories authorized by the legislature to jump the queue (military dependents, people with Phelan-McDermid
Syndrome, and people in ICFs or nursing facilities), see s. 393.064(6), (7), F.S. See, Agency for Persons with Disabilities,
Quarterly Report on Agency Services to Floridians with 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).
30
Section 409.972(1)(e), F.S. BILL: CS/CS/SB 1084 Page 10
Person-Centered Planning
Currently, all iBudget recipients are required to receive case management and person-centered
planning.
31
A person-centered service plan reflects the services and supports that are important to
the individual in meeting their long-term goals, and the preferences for the delivery of such
services and supports.
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 population, including primary care, acute care, behavioral health, and long-term care
services. Tennessee takes a similar approach, but its managed care plans do not bear risk.
32
New York obtained a federal waiver to transition the Medicaid developmental disability
population into managed care based on a phased-in model, beginning with integrated care
coordination under a single, comprehensive plan. In addition, New York operates a service
delivery model that fully integrates with Medicare coverage, for persons eligible for both
programs, offering primary, acute, long-term care, and habilitation services.
33
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.
34
Florida does not use a risk-based managed care model for HCBS services, and the Medicaid
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 individual enrollees.
31
42 C.F.R. 441.301(c)(1)
32
National Association of States United for Aging and Disabilities, MLTSS Institute, “MLTSS for People with 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).
33
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 viewed March 24, 2023).
34
Id. BILL: CS/CS/SB 1084 Page 11
III. Effect of Proposed Changes:
Managed Care Pilot Program for Individuals with Developmental Disabilities
CS/SB 1084 creates s. 409.9855, F.S., to establish a Medicaid managed care pilot program to
provide home and community-based services to individuals with developmental disabilities. The
pilot program will operate in Hardee, Highlands, Hillsborough, Manatee, Polk, Miami-Dade and
Monroe counties (Medicaid regions D and I). The Agency for Health Care Administration
(AHCA) is required to seek federal approval to implement the pilot program by September 1,
2023.
Under the pilot program the AHCA is responsible for the following:
Seeking federal authority to amend the Medicaid state plan or Medicaid waiver as necessary
to implement the pilot program;
Adopting rules necessary to comply with any federal requirements related to the pilot
program and implementation of the pilot program;
35
Negotiating with and selecting qualified plans to participate in the pilot program;
Ensuring that the rate setting methodology is inclusive of the intent to provide individualized,
quality care in the least restrictive setting;
Making payments for services under the pilot program;
Ensuring minimum contract standards are met, including, but not limited to, data collection,
access, quality care, complaint resolution, claims payment, and transparency;
36
Evaluating the feasibility of statewide implementation of the capitated managed care model
used by the pilot program to serve individuals with developmental disabilities;
Delegating specific duties to the Agency for Persons with Disabilities (APD);
In consultation with the APD:
o Making enrollment offers;
o Ensuring that a statistically valid population is sampled to participate in the pilot
program;
o Considering specified factors in the selection of eligible plans;
o Conducting audits of the selected plans’ implementation of person-centered planning;
o Auditing selected plans implementation of person-centered planning;
o Providing progress reports on implementation of the pilot program, and annual reports on
operation of the pilot program; and
o Evaluating specific measures of access, quality, and costs of the pilot program.
Under the pilot program, the APD is responsible for the following:
Approving a needs assessment methodology to determine functional, behavioral, and
physical needs of prospective enrollees. The methodology may be administered by persons
who have completed such training as may be offered by the AHCA.
Being a part of the negotiating team that selects plans to participate in the pilot program; and
35
The bill specifies, that unless otherwise stated ss. 409.961-409.969, F.S., apply to the pilot program. As such, s. 409.961,
F.S., authorizes the AHCA to adopt rules as necessary to comply with federal requirements and administer the Medicaid
Managed Care Program.
36
The bill specifies, that unless otherwise stated ss. 409.961-409.969, F.S., apply to the pilot program. As such, s.
409.967(2), F.S., requires the AHCA to establish minimum contract requirements. BILL: CS/CS/SB 1084 Page 12
Developing rules to implement the bill and ensure that an enrollee receives an individualized
transition plan to assist him or her in accessing sufficient services and supports for the
enrollee’s safety, well-being, and continuity of care.
Participant Eligibility
Participation in the pilot program is limited to the maximum number of enrollees specified in the
General Appropriations Act, if any. The AHCA, in consultation with the APD, is required to
make enrollment offers and to ensure that enrollment is sufficiently diverse to conduct a
statistically valid evaluation of the pilot program within three years. The pilot program will be
available, on a volunteer basis, to Medicaid eligible individuals who:
Are Medicaid-eligible and 18 years of age or older;
Have been assigned to category 1, 2, 3, 4, 5 or 6 on the iBudget waitlist; and
Reside in a pilot program region.
Pilot Program Benefits
The plans participating in the pilot program must, at a minimum, provide the following services
through a single, integrated model of care:
Medical care benefits described in s. 409.973, F.S., including access to prepaid dental plans;
Long-term care benefits described in s. 409.98, F.S.;
Home and community-based services described in 393.066, F.S.; and
Services currently listed in the Florida Medicaid Developmental Disabilities Individual
Budgeting Waiver Services Coverage and Limitations Handbook, and prevocational services.
Services must be provided in accordance with an individualized care plan that is evaluated and
updated as warranted by changes in a participant’s circumstances. Support coordination services
provided under the plan must maximize the use of natural supports and community partnerships.
All service providers of home and community-based services under the pilot program must meet
the same provider qualifications as service providers under the iBudget waiver. The iBudget
waiver service provider qualifications are outlined in the Florida Medicaid Developmental
Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook.
37
Plan Eligibility and Selection
For a plan to be selected to participate in the pilot program, the plan must have been awarded a
contract as a result of the invitation to negotiate, ITN-04836, for Statewide Medicaid Managed
Care Program which was issued on April 11, 2023. The AHCA must select one plan for each
region of the pilot program.
The AHCA must select the plans, with which they will negotiate, based on specific criteria that
must include, but is not limited to, the following:
Experience serving similar populations and achieving specific quality standards.
Establishment of provider partnerships that create opportunities for re-investment in
community-based services;
37
See, Rule 59G-13.070, F.A.C. BILL: CS/CS/SB 1084 Page 13
Provision of additional benefits including behavioral health services, coordinated dental care,
and mental health therapy and analysis;
Evidence of established relationships with providers;
Experience in the provision of person-centered planning; and
Experience in provider development program that result in increased availability of providers
to serve individuals with developmental disabilities.
The APD is required to be a part of the negotiating team. After negotiations are complete
preference will be given to plans that:
Have signed contracts in sufficient numbers to meet the access standards specified in s.
409.967, F.S., including contracts for personal supports, skilled nursing, residential
habilitation, adult day training, mental health services, respite car, companion services, and
supported employment;
Have well-defined programs for recognizing patient-centered medical homes, and providing
increased compensation to recognized medical homes;
Have well-defined programs related to person-centered planning; and
Have robust and innovative provider development programs.
Disenrollment
Enrollees must be given an opportunity to disenroll from the pilot program and enroll in any
appropriate existing Medicaid waiver program if any of the following conditions occur:
At any point during the operation of the pilot program, an enrollee declares an intent to
voluntarily disenroll, provided that he or she has been covered for the entire previous plan
year by the pilot program.
At any point during the operation of the pilot program, the plan does not have sufficient
enrollees to appropriately provide adequate services to its enrollees.
Upon the pilot program ceases to operate.
Plan Accountability
Managed care plans participating in the pilot program must meet the accountability measures
required by ss. 409.967, 409.975, and 409.982, F.S. The bill requires the AHCA to include the
same accountability measures required of managed care plans, in its contract with participating
plans that are selected to participate in the pilot program. These measures include, but are not
limited to, the following:
Participation in the achieved savings rebate program;
38
Performance measures related to access, quality care, grievance resolution, prompt payment,
and transparency, among others;
39
Compliance with the AHCA’s reporting requirements;
40
Development and maintenance of adequate provider networks;
41
38
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 which are tied to achieving AHCA-defined quality measures.
Section 409.967(3)(f), F.S.
39
Section 409.967, F.S.
40
Section 409.973(2)(e), F.S.
41
Section 409.975 (1), F.S. BILL: CS/CS/SB 1084 Page 14
Establishment of provider quality and performance monitoring;
42
Development of negotiated, mutually acceptable provider rates and terms of payment;
43
and
Specific standards for the number, type, and distribution of providers in the plan’s network,
as developed by the AHCA.
44
In addition, the bill requires the plans must have provider capacity within a maximum travel
distance of 15 miles for urban areas and 30 miles for rural areas, for the provision of specialized
therapies, adult day training, and prevocational training.
Plans must consult with the APD prior to placing a pilot program participant in a group home
licensed by the APD.
Plan Payment
The plans will receive an actuarially sound per-member, per-month payment. The bill requires
the rate-setting methodology used to develop the rate to reflect the intent to provide
individualized, quality care in the least-restrictive setting.
Pilot Program Reporting and Evaluation
The bill requires the AHCA to evaluate the feasibility of statewide implementation of the
capitated managed care model used by the pilot program.
Upon implementation of the pilot program, the bill authorizes the AHCA, in consultation with
the APD to conduct audits of the plan’s implementation of person-centered planning and quality
assurance monitoring. Quality assurance monitoring must include client satisfaction with
services, health and safety outcomes, well-being outcomes, and service delivery in accordance
with the client’s care plan.
Additionally, the AHCA, in consultation with the APD, must submit the following reports:
By December 31, 2023, a report on the progress made toward federal approval of the pilot
program.
By December 1, 2024, a report on the progress made toward full implementation of the pilot
program.
By December 1, 2025, and annually thereafter, a report on the operation of the pilot program,
including, but not limited to, the following:
o Program enrollment data;
o Any complaints received; and
o Access to approved services.
By October 1, 2029, an evaluation of the pilot program, including, but not limited to, the
following:
o Specific measures of access, quality, and costs;
o Assessments of cost savings;
o Consumer education, choice, and access to services;
o Plans for future capacity and the enrollment of new Medicaid providers;
42
Section 409.975(3), F.S.
43
Section 409.975(6), F.S.
44
Section 409.982(4) BILL: CS/CS/SB 1084 Page 15
o Coordination of care;
o Person-centered planning, and person-centered well-being outcomes;
o Health and quality-of-life outcomes;
o Quality of care; and
o Any barriers to implementation and operation of the pilot program.
The evaluation required by the bill must be submitted to the Governor, the President of the
Senate, and the Speaker of the House of Representatives by October 1, 2029.
The pilot program is repealed on October 2, 2029, after the submission of the program
evaluation, unless reviewed and saved from repeal by the Legislature.
The bill takes effect upon becoming a 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.
E. Other Constitutional Issues:
None.
V. Fiscal Impact Statement:
A. Tax/Fee Issues:
None.
B. Private Sector Impact:
Persons who enroll in the pilot will experience an increase in home and community-based
services.
An organization awarded a contract under the pilot program will benefit financially from
the bill’s implementation, if that organization is able to successfully manage services BILL: CS/CS/SB 1084 Page 16
rendered to program participants. The Agency for Health Care Administration (AHCA)
has not provided an analysis of the bill; therefore, the number of managed care
organizations, if any, who currently meet the bill’s qualifications, or could potentially be
created to meet those qualifications, is unknown.
C. Government Sector Impact:
The bill will have a significant negative fiscal impact on state expenditures. The pilot
program limits participation to the maximum number of enrollees specified in the
General Appropriations Act.
Currently, House Bill 5001, the House proposed 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 iBudget waiting list and who
voluntarily choose to participate in the pilot program.
The Agency for Persons with Disabilities estimates the average annual cost for a non-
crisis enrollee on the iBudget Waiver is $53,136. Therefore, the estimated cost to provide
home and community-based services to 600 individuals who are on the waitlist, and who
are not in crisis, is $31.8 million ($12.9 million GR; $18.9 million TF).
45
The bill will likely have an indeterminate yet negative fiscal impact on both the AHCA
and the APD due to the responsibilities required of both agencies under the bill.
However, the fiscal impact is likely to be realized in Fiscal Year 2024-2025 when
contracts are awarded and implementation of the pilot program begins.
VI. Technical Deficiencies:
None.
VII. Related Issues:
None.
VIII. Statutes Affected:
This bill substantially amends section 409.981 of the Florida Statutes.
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 Fiscal Policy Committee on April 25, 2023:
The committee substitute:
Specifies that the AHCA will administer the program in consultation with the APD.
45
This estimate excludes medical costs provided to people with developmental disabilities currently covered by Medicaid. BILL: CS/CS/SB 1084 Page 17
Allows enrollees in the pilot to disenroll and enroll in the iBudget or other appropriate
waiver under the following circumstances:
o An individual enrolled in the pilot for at least one year decides to disenroll;
o The pilot does not have sufficient enrollees to provide adequate services at any
point; or
o Upon the cessation of the pilot program.
Provides eligibility criteria for enrollment to include individuals 18 and older in
waitlist categories 1 – 6, which will ensure that individuals in crisis also have an
opportunity to receive services if they reside in one of the two pilot regions. The bill
previously allowed enrollment for individuals in categories 3 – 6.
Requires the AHCA, in consultation with the APD, to make enrollment offers to
eligible individuals and to ensure that a statistically valid population is sampled to
participate in the pilot program.
Requires the AHCA, in consultation with the APD, to consider specified factors in
the selection of eligible plans.
Requires support coordination services to maximize the use of natural supports and
community partnerships, rather than community services.
Specifies that plans participating in the pilot program must consult with the APD
before placing an enrollee of the pilot program in a group home licensed by the APD.
CS by Appropriations Committee on Health and Human Services on April 18, 2023:
The committee substitute:
Requires the AHCA to submit a request for federal approval to provide a managed
care service delivery system for providing medical, long-term, home and community-
based services to individuals with developmental disabilities, by September 1, 2023.
Requires that the AHCA to delegate specific duties and responsibilities to the Agency
for Persons with Disabilities (APD).
Expands the pilot program from only Miami-Dade County, to Medicaid regions D
and I, which include Hardee, Highlands, Hillsborough, Manatee, Polk, Miami-Dade
and Monroe counties.
Expands the list of services that must be provided to include all of the 27 services
currently provided by the APD through the iBudget waiver.
Requires that home and community-based service providers under the pilot program
to meet the same provider qualifications currently required of providers under the
iBudget waiver.
Requires the maximization of natural and community supports prior to the utilization
of state resources.
Requires the APD to conduct an initial needs assessment to determine an individual’s
level of need.
Specifies participant eligibility, to include individuals who are 21 years of age or
older, who are currently in certain categories on the waitlist, and who reside in the
pilot areas.
Requires the APD to make pilot program enrollment offers, under certain
circumstances and to a specified population, to ensure a statistically valid test of the
pilot program can be conducted within 3 years. BILL: CS/CS/SB 1084 Page 18
Expands the types of entities that may be awarded a contract to implement the pilot
program to include any plan that is awarded a contract to provide long-term care
services under the AHCA’s Statewide Medicaid Managed Care invitation to
negotiate, which was released on April 11, 2023. The underlying bill limited the type
of plan that could be awarded a contract to only a provider service network.
Requires the selected plans to meet additional criteria, including:
o Provider capacity within a certain distance for the provision of certain services;
o Experience serving similar populations and achieving specific quality standards;
o Establishment of provider partnerships that create opportunities for re-investment
in community-based services;
o Provision of additional benefits including behavioral health services, coordinated
dental care, and mental health therapies;
o Evidence of established relationships with providers;
o Experience in the provision of person-centered planning; and
o Experience in provider development program that result in increased availability
of providers to serve individuals with developmental disabilities.
Authorizes the AHCA to give preference in awarding contracts to plans that meet the
following additional criteria:
o Have a sufficient amount of signed contracts for the provision of certain home
and community-based services;
o Have well-defined programs for recognizing patient-centered medical homes,
such as those that serve people with intensive behaviors, and providing increased
compensation to recognized medical homes;
o Have well-defined programs related to person-centered planning; and
o Have robust provider development programs.
Authorizes the AHCA to pay selected plans a capitated per-member, per-month
payment based on a new actuarially sound rate-setting methodology specific to
providing developmentally disabled individuals with individualized, quality care in
the least restrictive setting. The underlying bill was less specific only requiring that
the plan be paid a risk-adjusted capitation rate.
Requires the AHCA to include the inclusion of serving individuals with
developmental disabilities in the dental-capitation-rate-setting methodology.
Authorizes the APD to conduct audits of the plan’s implementation of person-
centered planning and quality assurance monitoring of the pilot program.
Requires the APD to submit a report on progress made toward federal approval and
implementation of the pilot program, by certain dates.
Requires the APD to submit a report by December 31, 2025 and annually thereafter,
on the operation of the pilot program.
Requires the APD and the AHCA, to conduct an evaluation of the pilot program and
submit a report to the Governor, the President of the Senate, and the Speaker of the
House of Representatives by October 1, 2029.
Repeals the pilot program after October 2, 2029, unless reviewed and saved from
repeal by the Legislature.
Authorizes the APD to develop rules to establish a process to enroll pilot program
participants onto the iBudget waiver upon the cessation of the pilot program. BILL: CS/CS/SB 1084 Page 19
B. Amendments:
None.
This Senate Bill Analysis does not reflect the intent or official position of the bill’s introducer or the Florida Senate.