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 Children, Families, and Elder Affairs
BILL: SB 550
INTRODUCER: Senator Rouson
SUBJECT: Transparency for Autism-related Services
DATE: December 11, 2023
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Hall Tuszynski CF Pre-meeting
2. AHS
3. FP
I. Summary:
SB 550 adds the new definition of “manifests” and “onset” to ch. 393, F.S. This effects the
defintions of “autism,” “developmental disability,” and “intellectual disability.”
The bill also requires the Agency for Persons with Disability to provide each applicant an
individualized eligibility determination that includes the specific criteria the applicant has not
met when denied.
The bill is expected to have an indeterminate negative fiscal impact on state government. See
Section V. Fiscal Impact Statement.
The bill is effective beginning July 1, 2024.
II. Present Situation:
Agency for Persons with Disabilities
The Agency for Persons with Disabilities (APD) is responsible for the provision of services to
individuals with developmental disabilities and for administering the Home and Community-
Based Services (HCBS) Waiver.
1
Florida has procured waivers of federal Medicaid requirements
for the purpose of providing home and community-based services to individuals at risk of
institutionalization.
2
The HCBS Waiver provides services to individuals with developmental
1
See Section 20.197(3), F.S.
2
Rule 59G-13.080(1), F.A.C.
REVISED: BILL: SB 550 Page 2
disabilities that allow them to continue to live in their home or home-like setting and avoid
institutionalization.
3
Eligible individuals must meet institutional level of care requirements.
4
The overarching goal for the APD is to prevent or reduce the severity of developmental
disabilities and implement community-based services that will help individuals with
developmental disabilities achieve their greatest potential for independent and productive living
in the least restrictive means.
5
In addition to central headquarters in Tallahassee, the APD operates a total of six regional offices
and 14 field offices throughout the state, as detailed below:
3
The Centers for Medicare and Medicaid Services, https://www.medicaid.gov/medicaid/home-community-based-
services/home-community-based-services-authorities/home-community-based-services-1915c/index.html (last visited Dec.
11, 2023).
4
Id.; Rule 59G-13.080(1), F.A.C.
5
See Section 393.062, F.S. BILL: SB 550 Page 3
iBudget Florida Program
The APD administers Florida’s individual budget-based HCBS Waiver, known as iBudget
Florida, for individuals with specified developmental disabilities who meet Medicaid eligibility
requirements. These individuals may choose to receive services in the community through
iBudget Florida. Alternatively, they may choose to live in an institutional setting known as
Intermediate Care Facility for the Developmentally Disabled (ICF/DD)
6
through traditional
Medicaid administered by the Agency for Health Care Administration (AHCA).
7
The APD initiated implementation of iBudget Florida on May 1, 2011 with the final areas
transitioned from the previous teared waiver system on July 1, 2013.
8
The iBudget Florida
program uses an algorithm, or formula, to set individuals’ funding allocations for waiver
services.
9
The APD administers iBudget Florida pursuant to s. 393.0662, F.S.
The APD serves just over 34,900 individuals through iBudget Florida, contracting with service
providers to offer 27 supports and services to assist individuals to live in their community.
10
Examples of waiver services enabling children and adults to live, learn, and work in their
communities include residential habilitation, behavioral services, personal supports, adult day
training, employment services, and occupational and physical therapy.
11
Eligibility for iBudget Services
The application process for individuals wishing to receive services through the iBudget program
are detailed in s. 393.065, F.S. The APD must review applications for eligibility within 45 days
for individuals with developmental disabilities deemed to be in crisis
12
and within 60 days for all
other applicants.
13
Individuals who are determined to be eligible for the Waiver program are
either given a slot in the program or placed on a wait list. In fiscal year 2022-2023 APD reports
iBudget plans for 36,672 individuals. Due to demand exceeding available funding, individuals
with developmental disabilities who wish to receive HCBS services from the APD are placed on
a wait list for services in priority categories of need, unless they are in crisis. As of January 15,
2024, there were 21,587 individuals on the HCBS Waiver wait list.
14
6
Section 393.063(24), F.S., defines “intermediate care facility for the developmentally disabled” to mean a residential facility
licensed and certified under part VIII of ch. 400, F.S.
7
Section 393.0662, F.S.
8
The APD, Quarterly Report on Agency Services to Floridians with Developmental Disabilities and Their Costs: First
Quarter Fiscal Year 2022-23, p. 2, November 15, 2022,
https://apd.myflorida.com/publications/reports/docs/FY%202023%20Quarterly%20Report%201st%20Quarter%20report.pdf
(last visited Dec. 11, 2023).
9
Id.
10
Id.
11
Id.
12
See Rule 65G-1.047, F.A.C.
13
Section 393.065(1), F.S.
14
Email from Kendall Kelley, Legislative Affairs Director, Florida Agency for Persons with Disabilities, RE: Waitlist
number, Monday, January 15, 2024 11:16 AM (on file with the Senate Children, Families, and Elder Affairs Committee). BILL: SB 550 Page 4
The needs of APD clients are classified into seven categories and are prioritized in the following
decreasing order of priority:
15
Category 1 – Clients deemed to be in crisis.
Category 2 – Specified children from the child welfare system.
16
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 alternative 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 alternative 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 a meaningful day activity,
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 criteria for categories 1-5.
Category 7 – Clients younger than 21 years of age who do not meet the criteria for categories
1-4.
17
Because APD requires extensive documentation to verify identity, domicile, and documentation
of clinical eligibility, most applications are incomplete upon receipt and require additional time
to process. The APD also provides for a comprehensive assessment when needed to confirm
eligibility for an applicant.
Section 393.066, F.S. requires the APD to plan, develop, organize, and implement its programs
and services and treatment for persons with developmental disabilities to allow clients to live as
independently as possible in their own homes or communities and to achieve productive lives as
close to normal as possible.
18
All elements of community-based services must be made available,
and eligibility for these services must be consistent across the state.
19
15
Section 393.065(5), F.S.
16
See s. 393.065(5)(b), F.S., for specific criteria.
17
Section 393.065(5), F.S.
18
Section 393.066(1), F.S.
19
Id. BILL: SB 550 Page 5
Eligibility Criteria
Pursuant to 65G-4.017, F.A.C., there are eligibility criteria for each disability as follows:
Disability Eligibility Criteria
Autism
A diagnosis may only be made by one of the following:
A Florida-licensed psychiatrist;
A Florida-licensed psychologist;
A board-certified pediatric neurologist who is qualified by training and experience to
make a diagnosis of autism;
A board-certified developmental pediatrician; or
Collateral information received from another state may be accepted if the evaluator
is licensed through the same credentials required for licensure in Florida for the
professions listed above.
Cerebral Palsy
Diagnosis is confirmed by written documentation from:
A medical doctor;
A doctor of osteopathy; or
Medical records documenting a diagnosis of cerebral palsy before the age of 18.
Intellectual Disability
To establish that an individual has intellectual disability, the following criteria
shall be applied:
A single test should not be used alone to determine eligibility. If a person has a
great deal of variability on different scales or subtest scores of an IQ test, the full-
scale score may not indicate intellectual disability and should not be relied on as a
valid score. In that instance, closer scrutiny is required to make an appropriate
differential diagnosis. This may include a review of school records, school
placement, achievement scores, medical records, medication history, behavior
during testing, and the psychosocial situation at the time of testing. Closer scrutiny
must be required when there is a great deal of variability between IQ scores on
different IQ tests or different administrations of the same test.
The performance measures for this category must be validated by the professional
judgment of a psychologist who is experienced in working with people who have
intellectual disability, who has specific training and validation in the assessment
instrument that is used, and who is one of the following:
o A Florida-licensed psychologist;
o A Florida-licensed school psychologist;
o A certified school psychologist.
Any standardized test may be submitted as proof, with specific tests presumptively
accepted.
Prader-Willi
Syndrome
Diagnosis is confirmed by written documentation from:
A medical doctor;
A doctor of osteopathy; or
Medical records that document a diagnosis of Prader-Willi syndrome before the age
of 18.
Spina Bifida
Diagnosis is confirmed by written documentation from one or more of the
following:
A medical doctor;
A doctor of osteopathy; or
Medical records that document a diagnosis of spina bifida cystica or
myelomeningocele before the age of 18.
Down Syndrome
Evidence requires medical records documenting a chromosome analysis (also
referred to as a karyotype) finding the individual has an extra genetic material
on their number 21 chromosome.
Phelan-McDermid
Syndrome
The diagnosis must be confirmed utilizing genetic testing, with written
documentation from:
A medical doctor;
A doctor of osteopathy; BILL: SB 550 Page 6
Disability Eligibility Criteria
High Risk Children,
ages 3-5
Evidence requires a determination by an APD area office that a medical
diagnosis of developmental delay evidenced by the child indicates a high
probability that the child is likely to have an eventual diagnosis of a qualifying
condition under Rule 65G-4.014, F.A.C., if early intervention services are not
provided, or the child has one or more physical or genetic anomalies
associated with specific developmental disabilities.
If a child between three and five years of age already has been determined to have
a developmental disability in one of the five categories identified in chapter 393,
F.S., that a child shall be eligible for services from the agency under the appropriate
diagnosis and shall be added to a preenrollment category.
III. Effect of Proposed Changes:
Section 1 of the bill amends s.393.063, F.S., to include new definitions of “manifest” and
“onset” to be “the display or disclosure of characteristic signs or symptoms of an illness.”
This broadens the point in time in which the APD can consider the manifestation of specific
disabilities defined in statute. The definitions of “autism,” “developmental disability,” and
“intellectual disability” all use the term manifest or onset. . Currently, administrative rule
requires diagnosis by specific medical providers and/or specific tests, including intelligence tests
and genetic testing. These new definitions could result in individuals becoming eligible for
services prior to actual diagnosis as currently required.
Section 2 of the bill amends s. 393.065, F.S., to require the APD to provide any specific criteria
the applicant has not met from the APD’s eligibility criteria as described in administrative code
in their individual eligibility determination.
This language is a codification of the APD’s existing process of providing individual eligibility
determinations, but clarifies that specific eligibility criteria must be provided.
Section 3 provides an effective date for July 1, 2024.
IV. Constitutional Issues:
A. Municipality/County Mandates Restrictions:
None.
B. Public Records/Open Meetings Issues:
None.
C. Trust Funds Restrictions:
None. BILL: SB 550 Page 7
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:
None.
C. Government Sector Impact:
The APD reports an indeterminate but potentially significant negative fiscal impact to the
state. An increase in the eligible autism population would require an increase in needed
funding as follows per eligible individual:
Currently, the average cost plan for the iBudget Waiver is $58,356.61 based on
service allocations for FY 2022-23 for 36,672 clients.
The average costs for individuals using Individual and Family Supports (IFS) funding
during FY 2022-23 was $5,114 for approximately 2,548 clients.
For example, if the eligible population were to increase by only 50 individuals there
would be a needed increase in funding of:
50 (individuals) x $58,356.61(avg. iBudget plan) = $2,917,830.50, recurring
50 (individuals) x $5,114 (avg. IFS costs) = $255,700, recurring
Furthermore, a significant increase in population to the waiver program will require
provider development and additional staff. Currently, the APD has 4,863 providers that
provide iBudget Waiver services to approximately 36,672 clients.
VI. Technical Deficiencies:
The bill cites a specific rule in Florida’s Administrative Code. This should be generalized.
VII. Related Issues:
None.
VIII. Statutes Affected:
This bill substantially amends ss. 393.063 and 393.065, Florida Statutes. BILL: SB 550 Page 8
IX. Additional Information:
A. Committee Substitute – Statement of Changes:
(Summarizing differences between the Committee Substitute and the prior version of the bill.)
None.
B. Amendments:
None.
This Senate Bill Analysis does not reflect the intent or official position of the bill’s introducer or the Florida Senate.