This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h1271b.HCA
DATE: 1/26/2024
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/HB 1271 Individuals with Disabilities
SPONSOR(S): Children, Families & Seniors Subcommittee, Buchanan
TIED BILLS: IDEN./SIM. BILLS: SB 1758
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Children, Families & Seniors Subcommittee 15 Y, 0 N, As CS Lloyd Brazzell
2) Health Care Appropriations Subcommittee Fontaine Clark
3) Health & Human Services Committee
SUMMARY ANALYSIS
The Agency for Persons with Disabilities (APD) provides services to individuals with certain developmental
disabilities, including through a Medicaid Home and Community-Based Services (HCBS) waiver. The HCBS
waiver allows these individuals to continue to live in their own homes or in another home-like setting and avoid
institutionalization. Florida’s HCBS waiver for individuals with developmental disabilities is called iBudget
Florida (iBudget). Waiver applications are submitted through a paper-based process and then reviewed by
APD based on statutory deadlines. Most eligible individuals are initially placed on a pre-enrollment list; some
can wait for years before funding is available for waiver enrollment.
Applying and being determined eligible for the iBudget waiver can be confusing and frustrating. CS/HB 1271
enhances the individual’s eligibility and enrollment experience through:
Requiring an online application process;
Specifying the steps or documentation required to meet the definition of a “complete application”;
Requiring APD to communicate with applicants about certain application actions;
Specifying time standards for review and action on eligibility by pre-enrollment category.
The bill increases agency efficiency and improves access to services by:
Reprioritizing individuals whose caregivers are between 60 and 69 years old higher on the pre-
enrollment list (wait list);
Creating care navigation to assist individuals waiting for services in accessing community resources;
Limiting APD to developing support plans only for waiver enrollees;
Authorizing funding for enrolling on the waiver individuals in pre-enrollment categories 3-5; and
Requiring the Agency for Health Care Administration to contract with necessary experts, in consultation
with APD, for the development of a plan for a new Medicaid waiver for clients transitioning into
adulthood, which APD must submit by December 1, 2024.‘
The bill has a significant, negative fiscal impact on state government and no impact on local governments. The
bill provides a total appropriation of $38,852,223 to APD to enroll additional clients from the pre-enrollment list.
The bill has an effective date of July 1, 2024. STORAGE NAME: h1271b.HCA PAGE: 2
DATE: 1/26/2024
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Agency for Persons with Disabilities
The Agency for Persons with Disabilities (APD) provides services to certain individuals with
developmental disabilities.
1
APD supports these individuals and families in living, learning, and working
within their communities by creating multiple pathways to be successful through a variety of social,
medical, behavioral, residential, and therapeutic services.
2
Chapter 393, F.S., provides the authority and guidance to the APD on what programs to develop, who
is eligible, and how to manage those programs within available resources. In s. 393.062, F.S., the
legislative findings and declaration of intent state:
The greatest priority shall be given to the development and implementation of
community-based services that will enable individuals with developmental disabilities
to achieve their greatest potential for independent and productive living, enable them to
live in their own homes or in residences located in their own communities, and permit
them to be diverted or removed from unnecessary institutional placements.
One of the ways in which services are delivered to individuals with developmental disabilities is through
federal waivers, such as a Home and Community Based Services (HCBS) waiver
3
. The HCBS waiver
allows these individuals to continue to live in their own homes or in another home-like setting and avoid
institutionalization.
4
To qualify for this waiver, an individual must meet the standards for institutional
level of care.
5
Home and Community Based Waiver Programs
iBudget Florida Program
The APD also administers the Medicaid HCBS waiver known as iBudget Florida (iBudget) for
individuals with specified developmental disabilities who also meet Medicaid eligibility requirements.
6
The iBudget waiver provides home and community-based services and supports to eligible persons
with developmental disabilities living at home or in a home-like setting, with the costs shared with the
federal government. The services for this waiver are delivered through a Fee-For-Service (FFS)
delivery model, which means that providers are enrolled and reimbursed for services directly by the
Agency for Health Care Administration (AHCA).
The iBudget program allocates available funding to clients, providing each one with an established
budget with the flexibility to choose from the authorized array of services that that best meet their
individual needs within their community.
7
Each client has a waiver support coordinator who assists with
determining needs and coordinating providers to meet them.
1
S. 393.062, F.S.
2
Agency for Persons with Disabilities, About Us, available at About Us | APD - Agency for Persons with Disabilities - State
of Florida (myflorida.com) (last visited January 22, 2024).
3
Medicaid.gov, Home and Community Based Services – 1915(c), available at https://www.medicaid.gov/medicaid/home-
community-based-services/home-community-based-services-authorities/home-community-based-services-
1915c/index.html (last visited January 22, 2024).
4
Rule 59G-13.080(1), F.A.C.
5
Id.
6
S. 392.00662, F.S.
7
Id. STORAGE NAME: h1271b.HCA PAGE: 3
DATE: 1/26/2024
The iBudget program was phased in across the state beginning in May 2011 with the final area
transitioned from the old system on July 1, 2013.
8
The iBudget program uses an algorithm or formula to
set each participant’s funding allocation under the waiver.
9
According to APD, over 35,000 enrolled
individuals are currently receiving their services under the iBudget waiver program, and 21,000
individuals are on the pre-enrollment (wait) list for waiver services (see below).
Consumer Directed Care Plus Program
An individual who is enrolled on the iBudget waiver may choose to instead receive services through the
Consumer Directed Care Plus Program, or CDC+, Program. The CDC+ Program allows individuals
greater flexibility in the selection of providers and types of services and supports that may be
purchased using the individual’s budget. For instance, under CDC+, an individual and his or her family
can directly hire personal caregivers instead of using a Medicaid-enrolled provider. As in the waiver, a
support coordinator assists the individual and their families in identifying appropriate services and
supports and making those selections through the system, though under CDC+, this individual is known
as a consultant and has a more limited role.
10
Program Eligibility
To receive services from APD, an individual must be found eligible through a paper application
submission process. Information from the paper application is manually keyed into an electronic client
data management system and reviewed both for eligibility based on information on the application and
to identify if any additional information is needed. The APD determines eligibility based on Florida
statutes and rules.
To be eligible, an individual must:
Demonstrate evidence that one of the following developmental diagnoses manifested itself
before the age of 18 and can reasonably be expected to continue indefinitely:
o Intellectual disability.
o Spina Bifida.
o Cerebral palsy.
o Autism.
o Down syndrome.
o Phelan McDermid syndrome.
o Prader-Willi syndrome.
11
Be domiciled in Florida;
12
and
Be at least three years of age.
13
The APD must review an application within 60 days depending on individual circumstances and the
documentation received.
14
Additional time to work with the applicant may be needed, for example, to
conduct a comprehensive assessment to determine if the individual meets the clinical eligibility
requirements.
8
The Agency for Persons with Disabilities, Quarterly Report on Agency Services to Floridians with Developmental
Disabilities and their Costs: First Quarter Fiscal Year 2022-23, p.2, November 15, 2022, available at
https://apd.myflorida.com/publications/reports/ (last visited January 22, 2024).
9
Id.
10
A support coordinator is defined in s. 393.063(37), F.S. Further responsibilities are also included in the Agency for
Health Care Administration, Consumer Directed Care Plus Program Coverage, Limitations, and Reimbursement
Handbook (October 2015), available at https://apd.myflorida.com/cdcplus/docs/CDC_Plus_Program_Handbook_2015.pdf
(last visited January 22, 2024).
11
S. 393.063(11), F.S. and 393.065, F.S.
12
S. 393.063(13), F.S. and 393.065, F.S.
13
Supra, note 2.
14
S. 393.065(1), F.S. STORAGE NAME: h1271b.HCA PAGE: 4
DATE: 1/26/2024
For an applicant deemed in crisis, APD must expedite the application review to within 45 days.
15
If
additional documentation is needed, APD may pend the application until that information is provided
which would toll the clock until the information was provided by the applicant. Eligible individuals are
either enrolled in the program (provided a slot) or placed on the pre-enrollment list if the demand
exceeds the available funding.
16
The APD assigns each waitlisted client to a pre-enrollment category based on their needs and
prioritized in the following decreasing order of priority:
17
Category 1: Clients deemed to be in crisis.
Category 2: Children in the child welfare system at the time of permanency or turning 18.
Category 3: Intensive Needs
Category 4 : Caregiver over the age of 70
Category 5: Transition from School
Category 6: Age 21 and Over
Category 7: Age under 21
Eligible individuals that meet the criteria for Categories 1 or 2 are directly enrolled onto the iBudget
waiver. Currently, there is a higher demand for iBudget services than the funding available, which
means individuals who require services are put on the pre-enrollment list based on the categorization of
their needs.
As of December 2023, as the table shows below, over 21,000 individuals were waiting for services, with
approximately 50 percent of those between 25 through 59 years old.
18
iBudget Pre-Enrollment List
December 2023
19
Category Description Total Clients
Category 1 Crisis 0
Category 2 Children in welfare system at the time
of permanency or turning 18
0
Category 3 Intensive Needs 210
Category 4 Caregiver over age 70 83
Category 5 Transition from School 20
Category 6 Age 21 and Over 12,809
Category 7 Age under 21 8,464
Grand Total: 21,587
For each client in a pre-enrollment category, APD develops a support plan and sends an annual status
letter. During this annual check-in, APD verifies contact information, provides resources information,
and also provides the family an opportunity to indicate if there are any new unmet needs or other
changes that may impact the individual’s eligibility.
20
The APD has recently begun providing care
navigation to these clients, using positions that were repurposed for that effort.
When an individual is deemed eligible for services, the APD is required to consult with the client, if the
client is competent, if not then the client’s parent or guardian to devise a support plan. For children
ages 3 to 18 and other individuals, the support plan must include the most appropriate, the least
15
Id.
16
Rule 65G-1.047, F.A.C. The rule provides that the severity of the crisis is determined by the risk to the health, safety,
and welfare of each applicant relative to other applicant. Rule 65G-11.004 provides a procedure for determining if a client
is considered to be in crisis.
17
Supra, note 12.
18
Id.
19
Supra, note 12.
20
Id. STORAGE NAME: h1271b.HCA PAGE: 5
DATE: 1/26/2024
restrictive, and most cost beneficial environment for the individual’s progress, and have the appropriate
specification for the services authorized.
21
Effect of the Bill
Care Navigators
CS/HB 1271 authorizes the APD to offer clients and their caregivers care navigation services within
available resources at the time of application and as part of any eligibility or renewal review. A care
navigator would assist the client and the client’s family with navigating the systems and accessing
services, supports, and available resources to meet an individual non-waiver enrolled client’s needs, as
well as identifying and addressing any barriers preventing individuals from accomplishing their goals.
The care navigator would also connect individuals to supports and services in a timely manner and
address immediate or critical needs to stabilize the individual seeking assistance before the individual
reaches a crisis point.
Under s. 393.064, F.S., a care navigator would be involved in activities such as assessing client needs,
developing care plans, and connecting individuals to resources that address the individual’s immediate,
intermediate, and long-term needs, goals leading to increased opportunities in education, employment,
social engagement, community integration, and caregiver support.
For an individual who is also a public school student, the student’s Individuals with Disabilities
Education Act (I.D.E.A.) plan, as amended, would also be incorporated into the care plan.
Online Application
CS/HB 1271 modernizes the application and eligibility processes at APD to incorporate a requirement
for an online application, identify the federal time standards for eligibility review and processing, specify
the steps for a complete application, and provide specificity for eligibility determination time standards.
With only a paper application currently available, CS/HB 1271 requires APD to develop and implement
an online application process and system that meets certain minimum requirements, including the
directive to:
Create and maintain a paperless, electronic application.
Maintain access to a printable, paper application on the APD website.
Provide paper applications upon request.
Designate a central or regional address for submission of paper applications via regular U.S. mail or
via confidential fax.
Provide immediate confirmation of receipt in the same manner as application was submitted, unless
the applicant has designated otherwise.
For those individuals seeking enrollment in the HCBS waiver program who identify as being in crisis, the
APD must make an eligibility determination in an expedited manner of 15 calendar days after receipt of
a completed application. To be considered a completed application, the application must:
Include a signature and date by the applicant or someone with legal authority to apply for public
benefits on behalf of the applicant.
Be responsive on all parts of the application.
Contain documentation of a diagnosis.
For individuals with developmental disabilities who meet the criteria in s. 393.065(5)(b), F.S., which are
children who are in the child welfare system (Category 2 on the pre-enrollment list), the APD must make
eligibility determinations as soon as practicable. For the remaining categories under s. 393.065, F.S.,
CS/HB 1271 requires an eligibility determination standard of 60 days after receipt of a complete
application. The APD may toll the clock on the 60 day time period if documentation is missing; however,
21
S. 393.0651, F.S. STORAGE NAME: h1271b.HCA PAGE: 6
DATE: 1/26/2024
APD must convey this delay to the client verbally as soon as the action is taken and follow up with a
written confirmation which details the anticipated length of the delay and a contact person for the client
to reach should he or she have questions.
The bill amends the individual support plan requirement in s. 393.0651, F.S., to limit that requirement to
only individuals served by the current iBudget waiver. CS/HB 1271 adds a time standard of 60 calendar
days after an APD eligibility determination for the development of the individual support plan and a
requirement that the waiver support coordinator specifically inform the client, the client’s parent or
guardian about the CDC+ program. This will ensure that individuals eligible for CBC+ are informed about
the opportunity.
Category 4 Expansion
The Category 4 pre-enrollment category is also modified. Instead of this category including those
individuals whose caregivers are aged 70 of age or older, and for whom a caregiver is required but no
alternate caregiver is available, CS/HB 1271 reduces the qualifying age in the category for the caregiver
to 60 years old. This will make more individuals eligible in a higher priority category, likely moving from
category 6 up to category 5, and providing help to caregivers sooner.
Waiver Study
The AHCA, APD, and other stakeholders are directed to work together to jointly develop a
comprehensive plan for the administration, finance, and delivery of a new HCBS Medicaid waiver
program focused on successfully transitioning clients into adulthood and proactively preventing crisis
situations. The AHCA is authorized to contract with the necessary experts, in consultation with APD, to
develop the plan. APD; however, is responsible for the submission of the final report, in consultation with
AHCA, to the Governor, the President of the Senate, and the Speaker of the House of Representatives
by December 1, 2024. The report must specifically address, at a minimum:
The purpose, rationale, and expected benefits of the new waiver program.
The proposed eligibility criteria for clients and the service benefit package to be offered through the
waiver.
A proposed implementation plan and timeline, including the recommended number of clients to be
served at implementation and at different program intervals.
Proposals for how clients may transition off and on the program and between other designated
waiver programs.
The fiscal impact of the program for the implementation year and over the next five fiscal years,
determined on an actuarially sound basis.
An analysis of the availability of the services that would be offered under the waiver program and
recommendations for how to increase access, if necessary.
A list of participating stakeholders, public and private, involved in or consulted about the proposed
waiver program.
The effective date of the bill is July 1, 2024.
B. SECTION DIRECTORY:
Section 1: Amends s. 393.064; F.S.; Care navigation.
Section 2: Amends s. 393.065, F.S.; Application and eligibility determination.
Section 3: Amends s. 393.0651, F.S.; Family or individual support plan.
Section 4: Provides an appropriation.
Section 5: Creates an unnumbered section of law, related to a report.
Section 6: Provides an effective date of July 1, 2024.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
STORAGE NAME: h1271b.HCA PAGE: 7
DATE: 1/26/2024
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
The bill appropriates a recurring total of $38,852,223 ($16,333,475 from the General Revenue Fund
and $22,518,748 the Operations and Maintenance Trust Fund) to expand HCBS waiver services to
additional clients. This funding is expected to offer waiver services to individuals from pre-
enrollment categories 3, 4, and 5.
The bill requires the agency to implement an electronic application process. The agency indicates
a cost of between $1,750,000 to $1,850,000 to develop the system, based upon the level of
sophistication desired. Total implementation may take longer than a year.
22
Based on a review of
historical reversions, the agency has sufficient existing resources to begin system development
during FY 2024-25. APD can submit a Legislative Budget Request for the following year to request
the additional resources needed to complete the system and for recurring maintenance needs.
The bill requires APD to collaborate with AHCA and other stakeholders to develop a plan for the
administration, finance, and delivery of a new HCBS Medicaid waiver. The new program will
transition clients into adulthood by offering services to prevent crisis situations. The House
proposed General Appropriations Act for FY 2024-25 provides $800,000 for actuarial services to
determine appropriate capitation rates for the newly-created program.
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
The bill does not appear to affect local governments.
2. Expenditures:
None.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
Those individuals enrolled on the waiver under the bill will receive additional supports and services.
The number of individuals who will be enrolled on the waiver under the bill is unknown, as under the
iBudget waiver the specific budget for each individual is determined after enrollment.
Providers of services to these individuals will have increased revenue.
D. FISCAL COMMENTS:
None.
III. COMMENTS
A. CONSTITUTIONAL ISSUES:
1. Applicability of Municipality/County Mandates Provision:
Not applicable. The bill does not appear to affect county or municipal governments.
2. Other:
22
Supra, Note 12. STORAGE NAME: h1271b.HCA PAGE: 8
DATE: 1/26/2024
None.
B. RULE-MAKING AUTHORITY:
The Agency for Persons with Disabilities has sufficient rule-making authority to implement the
provisions of this bill.
C. DRAFTING ISSUES OR OTHER COMMENTS:
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES
On January 24, 2024, the Children, Families, and Seniors Subcommittee adopted two amendments and
reported the bill favorably as a committee substitute. The amendments:
Define the term “complete application,” which means an application that:
o Has been signed and dated,
o Is responsive on all parts, and
o Contains documentation of a diagnosis.
Identify the Agency for Persons with Disabilities (APD) as responsible for the report on the waiver
study, and require the Agency for Health Care Administration (AHCA) to consult APD when hiring any
experts to assist with the study.
The analysis is drafted to the committee substitute as passed by the Children, Families, and Seniors
Subcommittee.