This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h1271d.HHS
DATE: 2/21/2024
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/CS/HB 1271 Individuals with Disabilities
SPONSOR(S): Health Care Appropriations Subcommittee, 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 15 Y, 0 N, As CS Fontaine Clark
3) Health & Human Services Committee Lloyd Calamas
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 expands the iBudget program and improves service delivery 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
The bill authorizes planning for a new Medicaid HCBS waiver for a new population. It requires 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. APD must submit a report on the
plan to the Legislature and Governor by December 1, 2024.
The bill provides a total appropriation of $38,852,223 in recurring fund to APD and has no fiscal impact on local
government.
The bill has an effective date of July 1, 2024. STORAGE NAME: h1271d.HHS PAGE: 2
DATE: 2/21/2024
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 the Home and Community Based Services (HCBS) waiver
3
. The HCBS
waiver allows 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 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 waiver services 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 best meet their individual
needs within their community.
7
Individual waiver support coordinators client assist each client with
determination of his or her unique needs and the coordination of necessary providers to provide those
services.
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: h1271d.HHS PAGE: 3
DATE: 2/21/2024
Beginning May 2011, APD started the phase-in of the iBudget program statewide completing the final
transition from the old system on July 1, 2013.
8
The iBudget 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 elect to 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. Like the waiver, a
support coordinator assists the individual and his or her family with the identification of appropriate
services and supports and then makes those selections through the system. However, under CDC+,
this support 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 received at regional offices and is
manually keyed into an electronic client data management system. The application is reviewed for
eligibility based on application information and to identify if 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 clinical eligibility
requirements.
For an applicant deemed in crisis, APD must expedite the application review to completion 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
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.
15
Id. STORAGE NAME: h1271d.HHS PAGE: 4
DATE: 2/21/2024
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 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
restrictive, and most cost beneficial environment for the individual’s progress, and have the appropriate
specification for the services authorized.
21
Effects of the Bill
Care Navigators
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 w elfare 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
S. 363.065(5), F.S.
18
Agency for Persons with Disabilities, 2024 Agency Bill Analysis – HB 1271 (January 8, 2024)(on file with Children, Families & Seniors Subcommittee).
19
Id.
20
Id.
21
S. 393.0651, F.S. STORAGE NAME: h1271d.HHS PAGE: 5
DATE: 2/21/2024
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,
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 STORAGE NAME: h1271d.HHS PAGE: 6
DATE: 2/21/2024
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 eligibility category expands with CS/HB 1271 through the reduction of
the qualifying age of the older caregiver from age 70 or older to age 60 or older. For those individuals on
the waiver for whom a caregiver is required, whose caregiver is older but not yet 70, and there is no
alternate caregiver available, the reduction in the minimum age for priority 5 with CS/HB 1271 likely
makes more individuals eligible in a higher priority category. The caregiver age adjustment may move
an eligible individual from category 6 up to category 5, and provide help to caregivers sooner.
Waiver Plan
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
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
STORAGE NAME: h1271d.HHS PAGE: 7
DATE: 2/21/2024
The bill appropriates a recurring total of $38,852,223 ($16,562,703 from the General Revenue Fund
and $22,289,520 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:
None.
B. RULE-MAKING AUTHORITY:
22
Supra, Note 12. STORAGE NAME: h1271d.HHS PAGE: 8
DATE: 2/21/2024
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.
On January 29, 2024, the Health Care Appropriations Subcommittee adopted one amendment that
modifies the appropriation funding sources to reflect the most recently adopted Federal Medical Assistance
Percentage (FMAP). The total appropriation amount of $38,852,223 does not change; rather, the amounts
from the General Revenue Fund and the Operations and Maintenance Trust Fund are updated for the
FMAP fund split.
The analysis is drafted to the bill as amended and passed by the Health Care Appropriations
Subcommittee.