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 1758
INTRODUCER: Senator Brodeur
SUBJECT: Individuals with Disabilities
DATE: January 21, 2024
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Rao Tuszynski CF Pre-meeting
2. FP
I. Summary:
The Agency for Persons with Disabilities (APD) administers services to individuals with
developmental disabilities through federally funded Medicaid waiver programs. APD’s iBudget
program permits individuals to receive home and community-based waiver services and select
the services that are best suited for them while living in their home, rather than an institutional
setting.
SB 1758 modifies the application process for APD services, requiring the creation of an online
application process and streamlines the timeframes the APD has to determine eligibility.
When an individual applies for waiver services but funding is not available, the individual is
placed in a pre-enrollement category that prioritizes enrollment based on need.
The bill reduces the age requirement of a client’s caregiver in pre-enrollment category 4 from 70
years of age to 60 years of age or older. This will allow a higher number of individuals to be
included in category 4 of the pre-enrollment prioritization list.
Individuals may also be eligible for the consumer-directed care (CDC+) program, which is an
alternative to the iBudget program. In the CDC+ program, clients are permitted to use a monthly
budget allocation to purchase the long-term care services that they feel are the best fit for their
needs.
The bill requires iBudget waiver support coordinators to inform iBudget clients of the option to
apply for the CDC+ program when creating family or individual support plans.
The bill appropriates funding to the Agency for Persons with Disabilities for the 2024-2025
fiscal year and has a significant negative fiscal impact on state government. See Section V. Fiscal
Impact Statement.
REVISED: BILL: SB 1758 Page 2
The bill has an effective date of July 1, 2024.
II. Present Situation:
Agency for Persons with Disabilities – Generally
Chapter 393, F.S., identifies the need to provide community-based services and programs for
individuals with developmental disabilities that enable individuals to achieve their greatest
potential for independent living while reducing the number of individuals in unnecessary
institutional placements.
1
The Agency for Persons with Disabilities (APD) provides services to individuals with
developmental disabilities and manages Medicaid waivers that provide federally approved
services for individuals with developmental disabilities.
2
Florida has procured waivers of federal
Medicaid requirements for the purpose of providing home and community-based (HCBS)
services to individuals at risk of institutionalization.
3
The HCBS waiver provides services to
individuals with developmental disabilities that allow recipients to live in their home or a home-
like setting and avoid an institutional setting.
4
Eligible recipients must meet institutional level of
care requirements.
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:
6
1
Section 393.062, F.S.
2
Section 20.197, F.S.
3
Rule 59G-13.080(1), F.A.C.
4
The Centers for Medicare and Medicaid Services, 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 1/18/24).
5
Id.; Rule 59G-13.080(1), F.A.C.
6
Agency for Persons with Disabilities, Regional Offices, available at: https://apd.myflorida.com/region/ (last visited 1/18/24). BILL: SB 1758 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.
7
The iBudget program allocates available funding to eligible, Medicaid-enrolled
clients and provides the client an established budget with the flexibility to choose services within
a specified service package that best allows them to live in their community.
8
The APD began implementation of iBudget Florida on May 1, 2011; the final areas of the state
transitioned from the previous tiered waiver system on July 1, 2013.
9
The iBudget program uses
an algorithm, or formula, to set individuals’ funding allocations for waiver services.
10
The APD
administers the iBudget pursuant to s. 393.0662, F.S.
The APD serves approximately 35,000 individuals through iBudget Florida, contracting with
service providers to offer various supports and services to assist individuals to live in their
community.
11
Examples of waiver services include residential habilitation, behavioral services,
personal supports, adult day training, employment services, and occupational and physical
therapy.
12
Section 393.066, F.S., requires the APD to plan, develop, organize, and implement its programs
of services and treatment for persons with developmental disabilities to allow clients to live as
independently as possible in their own homes or communities.
13
All elements of community-
based services must be made available, and eligibility for these services must be consistent
across the state.
14
Services for clients must be purchased rather than provided directly by the
APD when more cost-efficient. However, the APD must approve all purchased services.
15
Eligibility for iBudget Services
Current Florida law requires the APD to review applications for eligibility of iBudget program
services within 60 days after receipt of the signed application. If the applicant is deemed to be in
crisis,
16
Florida law requires the APD to review eligibility determination within 45 days.
17
Individuals who are determined to be eligible for the Waiver program are either given a slot in
7
Section 393.0662, F.S.
8
Id.
9
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 1/18/24).
10
Id.
11
E-mail from Kendall Kelley, APD Legislative Affairs Director, January 19, 2024 (on file with the Senate Committee on
Children, Families, and Elder Affairs)
12
Supra. note 9.
13
Section 393.066(1), F.S.
14
Id.
15
Section 393.066, F.S.
16
Rule 65G-1.047, F.A.C. provides that the severity of crisis is determined by risk to the health, safety, and welfare of each
applicant relative to other applicants. Rule 65G-11.004 provides a procedure for determining if a client is considered to be in
crisis.
17
Section 393.065, F.S. BILL: SB 1758 Page 4
the program or placed on a wait list if the demand exceeds available funding. As of December
2023, there were 21,587 individuals on the waiting list.
18
The APD assigns each waitlisted client to a preenrollment category based on their needs and
prioritized in the following decreasing order of priority:
19
Category 1 – Clients deemed to be in crisis.
Category 2 – Includes clients in the preenrollment categories who are:
o From the child welfare system with an open case in the Department of Children and
Families’ statewide automated child welfare information system and who are either:
Transitioning out of the child welfare system into permanency; or
At least 18 years but not yet 22 years of age and who need both waiver services and
extended foster care services; or
o At least 18 years but not yet 22 years of age and who withdrew consent to remain in the
extended foster care system.
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 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 or whose caregiver is unable to provide the care needed.
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 a meaningful day activity,
maintain competitive employment, or 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.
Eligible individuals that meet the criteria for Categories 1 or 2 are directly enrolled onto the
iBudget waiver.
20
Currently, there is a higher demand for iBudget services than the amount of
funding that is available, which means individuals that require services are put on the waitlist for
services based on the categorization of their needs. The following table displays the number of
individuals in the preenrollemnt categories as of December 2023.
21
18
Supra note 11.
19
Section 393.065, F.S.
20
Agency for Persons with Disabilities, SB 1768 Analysis, p. 2 (on file with the Senate Committee on Children, Families, and
Elder Affairs)
21
Supra note 11. BILL: SB 1758 Page 5
Category Description Total Clients
Category 1 Crisis -
Category 2 Children in Welfare System at the time of permanency or
turning 18
-
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
The average time a client spends in a preenrollment category is 8.6 years.
22
The following chart
identifies the length of time clients have been in a preenrollment category.
23
Length of Time in a
Preenrollment Category
Percentage of
Individuals
Under 5 years 42%
5 –10 years 20%
10+ years 37%
iBudget Waiver Support Coordinators and Family Support Plans
After an individual is deemed eligible for services, the APD is required to consult with the client,
if competent, the client’s parent or guardian, or, when appropriate, the client advocate to create a
family or individual support plan.
24
A support plan must be designed to include the most
appropriate, least restrictive, and most cost-beneficial environment for the accomplishment of the
objectives for client progress, including an appropriate placement in the client’s home or
community.
25
Waiver support coordinators are permitted to review the progress of and annually revise the
family or individual support plan upon consultation with the client, the client’s parent or
guardian, or the client advocate.
26
Additionally, waiver support coordinators collaborate with the
recipient of services and service providers to accommodate the needs of the recipient within the
recipient’s iBudget services allocation.
27
22
Supra note 11.
23
Supra note 11.
24
Section 393.0651, F.S.
25
Id.
26
Id.
27
Agency for Health Care Administration, Developmental Disabilities Individual Budgeting Waiver Services Coverage and
Limitations Handbook, available at: https://apd.myflorida.com/ibudget/rules-regs.htm (last visited 1/18/24). BILL: SB 1758 Page 6
Florida Consumer-Directed Care Plus Program
The Legislature created the Florida Consumer-Directed Care Act in 2002 aimed to increase the
choice and control over long-term care services individuals with disabilities receive.
28
Authorized by the federal Medicaid State Plan Amendment, the Consumer-Directed Care Plus
(CDC+) program permits individuals to choose their providers and to direct the delivery of
services as they see fit, within the funds appropriated by the Legislature.
29
Consumers are able to use the monthly budget allowance to purchase long-term care services
which include, but are not limited to, the following:
30
Personal care.
Homemaking and chores, including housework, meals, shopping, and transportation.
Home modifications and assistive devices which may increase the consumer’s independence
or make it possible to avoid institutional placement.
Assistance in taking self-administered medication.
Day care and respite care services, including those provided by nursing home facilities or
adult day care facilities.
Personal care and support services provided in an assisted living facility.
To be eligible for the CDC+ Program, a recipient must:
31
Be enrolled in the Individual Budgeting Waiver (also known as the iBudget Waiver);
Reside in their own family home or the home of a relative; and
Not disenrolled from the CDC+ Program due to their mismanagement or inappropriate use of
Medicaid funds.
III. Effect of Proposed Changes:
Section 1 of the bill amends s. 393.065, F.S., to require the APD to develop and implement an
online application process for individuals applying for services from the agency. This online
application process must, at a minimum:
Support paperless, electronic submissions with immediate e-mail confirmation to each
applicant upon submission.
Permit an applicant to view the status of his or her application in the online application
system, and provide additional information.
The bill requires the APD to maintain a printable paper application on its website and provide
applicants with a printed paper application upon request. The bill allows applicants to apply for
services through writing to the agency in the region where he or she resides. This change
28
Chapter 2002-223, Laws of Florida.
29
Section 409.221(4), F.S.; Florida Agency for Health Care Administration, Federal Waivers, available at:
https://ahca.myflorida.com/medicaid/medicaid-policy-quality-and-operations/medicaid-policy-and-quality/medicaid-
policy/federal-authorities/federal-waivers (last visited 1/19/24).
30
Section 409.221, F.S.
31
Agency for Health Care Administration, Consumer-Directed Care Plus Program Coverage, Limitations, and
Reimbursement Handbook, available at: https://apd.myflorida.com/cdcplus/participants/ (last visited 1/19/24)/ BILL: SB 1758 Page 7
expands the options that applicants have for how they wish to submit their application for
services from the APD.
The bill requires the APD to review submitted applications in accordance with federal time
standards and changes eligibility determination timelines for individuals in a pre-enrollment
category. The bill defines “complete application” as an application submitted to the APD that is
signed and dated by the applicant or an individual with legal authority to apply for public
benefits on behalf of the applicant. The application must also have all parts filled out and
contains documentation of the applicant’s diagnosis to be considered a complete application.
The bill requires the following eligibility determination timelines for applicants requesting
enrollment in the home and community-based services Medicaid waiver program:
If the applicant meets the criteria for Category 1,
32
the APD is required to make an eligibility
determination within 15 calendar days after receipt of a complete application.
If the applicant meets the criteria for Category 2,
33
the APD is required to review the
application and make an eligibility determination as soon as practicable after receipt of a
complete application.
If the applicant meets the criteria for Categories 3-7,
34
the APD is required to make an
eligibility determination within 60 days after receipt of a complete application.
The bill requires the client to be informed through verbal contact (with the client or the client’s
designated caregiver) of any delays in the eligibility determination process or any tolling of the
time standards. This verbal contact must be confirmed with a written notice of the delay, the
anticipated length of delay, and a contact person for the client.
The bill reduces the age requirement of a client’s caregiver in category 4 from 70 years of age to
60 years of age or older. This change expands the number of clients who are eligible for category
4, allowing more individuals to be placed in a higher priority pre-enrollment category.
Section 2 of the bill amends s. 393.0651, F.S., to specify that the APD must provide directly or
contract for the development of a family support plan for clients served by the home and
community-based services Medicaid waiver program under s. 393.0662, F.S. Current law simply
states that each ‘client.’ This change recognizes that the APD provides services and supports to
many individuals that could be considered clients, but only those receiving services under the
HCBS waiver program require a support plan. The bill also specifies that the support plan must
be developed within 60 calendar days, not just 60 days as currently in statute.
The bill requires the waiver support coordinator to inform the client, the client’s parent or
guardian, or the client advocate about the CDC+ program established under s. 409.221, F.S.,
32
Section 393.065, F.S. includes clients deemed to be in crisis.
33
Section 393.065, F.S. provides that Category 2 includes clients in preenrollment categories who are from the child welfare
system with an open case in the Department of Children and Families’ statewide automated child welfare information system
and who are either: (a) transitioning out of the child welfare system into permanency; or (b) at least 18 years but not yet 22
years of age and who need both waiver services and extended foster care services. Clients who are at least 18 years but not
yet 22 years of age and who withdrew consent to remain in extended foster care are also included in Category 2.
34
See Section 393.065 for specific eligibility requirements. BILL: SB 1758 Page 8
which allows enrolled persons to choose the providers of services and to direct the delivery of
services to best meet their long-term care needs.
35
Section 3 of the bill appropriates the following funds for the 2024-2025 fiscal year:
$16,562,703 in recurring funds from the General Revenue fund and $22,289,520 in recurring
funds from the Operations and Maintenance Trust Fund are appropriated to the APD in the
Home and Community Based Services Waiver category. These funds are appropriated to offer
waiver services to the greatest number of individuals eligible. $38,852,223 in recurring funds
from the Medical Care Trust Fund is appropriated to the Agency for Health Care Administration
in the Home and Community Based Services Waiver category to establish budget authority for
Medicaid services.
Section 4 of the bill provides an effective date of July 1, 2024.
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 identified.
V. Fiscal Impact Statement:
A. Tax/Fee Issues:
None.
B. Private Sector Impact:
None.
35
Section 409.221, F.S. BILL: SB 1758 Page 9
C. Government Sector Impact:
The bill has an indeterminate negative fiscal impact on the APD to develop and
implement an online application process. This will likely require nonrecurring funds to
develop and implement and recurring funds to maintain and operate.
The bill appropriates funding to the Agency for Persons with Disabilities for services and
the Agency for Health Care Administration (AHCA) to establish budget authority for
Medicaid services: $16,562,703 in recurring funds from the General Revenue fund and
$22,289,520 in recurring funds from the Operations and Maintenance Trust Fund are
appropriated to the APD to the Home and Community Based Services Waiver category
and $38,852,223 in recurring funds to the AHCA.
VI. Technical Deficiencies:
None.
VII. Related Issues:
None.
VIII. Statutes Affected:
This bill substantially amends ss. 393.065 and 393.0651 of the Florida Statutes.
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.