STORAGE NAME: h1227d.HHS
DATE: 4/14/2025
1
FLORIDA HOUSE OF REPRESENTATIVES
BILL ANALYSIS
This bill analysis was prepared by nonpartisan committee staff and does not constitute an official statement of legislative intent.
BILL #: CS/HB 1227
TITLE: Medicaid Enrollment for Permanently Disabled
Individuals
SPONSOR(S): Tramont
COMPANION BILL: None
LINKED BILLS: None
RELATED BILLS: None
Committee References
Health Care Facilities & Systems
15 Y, 0 N, As CS
Health Care Budget
13 Y, 0 N
Health & Human Services
SUMMARY
Effect of the Bill:
The bill requires the Agency for Health Care Administration (AHCA) to seek federal approval to provide lifelong
eligibility for Medicaid and other forms of public assistance for permanently disabled Medicaid-qualified
individuals receiving Medicaid covered institutional care services, hospice services, or home and community-based
services through the iBudget Waiver program, or the Long-Term Care Waiver program. The bill authorizes AHCA to
disenroll such an individual from the Medicaid program if they have information that can conclusively document a
change in the person’s disability or economic status that would affect their eligibility.
Fiscal or Economic Impact:
The bill will have a negative fiscal impact on the Department of Children and Families (DCF) and AHCA.
(See Fiscal Impact on State Government Section)
JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
ANALYSIS
EFFECT OF THE BILL:
Under current Florida laws and regulations governing the Florida Medicaid program, Medicaid recipients must
undergo a Medicaid eligibility redetermination every 12 months, including permanently disabled recipients. Few
members of this population ever become disqualified for exceeding income and asset limits because their
permanent disability prevents them from receiving sufficient income through gainful employment.
The bill requires the Agency for Health Care Administration (AHCA) to seek federal approval to provide lifelong
eligibility for permanently disabled Medicaid-qualified individuals receiving Medicaid covered:
Institutional care services;
Hospice services; or
Home and community-based services in the iBudget waiver for persons with developmental disabilities or
in the Long-Term Care (LTC) managed care program. (Section 1)
If information becomes available that conclusively documents a change in the person’s disability or economic
status that would affect their eligibility, AHCA may disenroll the individual from the Medicaid program.
The bill provides an effective date of July 1, 2025. (Section 2)
JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
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FISCAL OR ECONOMIC IMPACT:
STATE GOVERNMENT:
The bill is expected to have a negative fiscal impact of $708,000 on DCF resulting from costs associated with
updating their online Medicaid application platform.
1 Based on an analysis of the unreserved cash in DCF’s trust
funds, the costs to the department can be absorbed within existing resources.
AHCA will also have costs to make procedural and system updates, but they can be absorbed with existing
resources. Additionally, AHCA expects the bill to have an indeterminate negative fiscal impact for the cost of
coverage for any enrollees who would have been identified as ineligible, but for the bill’s provisions.
2
RELEVANT INFORMATION
SUBJECT OVERVIEW:
Florida Medicaid
Medicaid is the health care safety net for low-income Floridians. Medicaid is a partnership of the federal and state
governments established to provide coverage for health services for eligible persons. The program is administered
by AHCA and financed by federal and state funds.
3 AHCA delegates certain functions to other state agencies,
including DCF, the Agency for Persons with Disabilities (APD), the Department of Health (DOH), and the
Department of Elderly Affairs (DOEA).
The structure of each state’s Medicaid program varies and what states must pay for is largely determined by the
federal government, as a condition of receiving federal funds. Federal law sets the amount, scope, and duration of
services offered in the program, among other requirements. These federal requirements create an entitlement that
comes with constitutional due process protections. The entitlement means that two parts of the Medicaid cost
equation – people and utilization – are largely predetermined for the states. The federal government sets the
minimum mandatory populations to be included in every state Medicaid program. The federal government also
sets the minimum mandatory benefits to be covered in every state Medicaid program. These benefits include
physician services, hospital services, home health services, and family planning.
4 States can add benefits, with
federal approval. Florida has added many optional benefits, including prescription drugs, adult dental services, and
dialysis.
5
States have some flexibility in the provision of Medicaid services. Section 1915(b) of the Social Security Act
provides authority for the Secretary of the U.S. Department of Health and Human Services (HHS) to waive
requirements to the extent that he or she “finds it to be cost-effective and efficient and not inconsistent with the
purposes of this title.” Section 1115 of the Social Security Act allows states to implement demonstrations of
innovative service delivery systems that improve care, increase efficiency, and reduce costs. These laws allow HHS
to waive federal requirements to expand populations or services, or to try new ways of service delivery.
Florida operates under a Section 1115 waiver to use a comprehensive managed care delivery model for primary
and acute care services, the Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA)
program. Florida also has waivers under Sections 1915(b) and (c) of the Social Security Act to operate the SMMC
Long-Term Care (LTC) program and the Development Disabilities Individual Budgeting (iBudget) Waiver.
6
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 (HCBS) designed to
keep people in their homes and communities instead of going into an institution when they need higher levels of
1 DCF, Agency Analysis of HB 1227 (March 17, 2025).
2 AHCA, Agency Analysis of HB 1227 (March 4, 2025).
3 Title 42 U.S.C. §§ 1396-1396w-5; Title 42 C.F.R. Part 430-456 (§§ 430.0-456.725) (2016).
4 S. 409.905, F.S.
5 S. 409.906, F.S.
6 S. 409.964, F.S. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
3
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.
Long-Term Care Home and Community-Based Services Program
Florida obtained a federal waiver to allow the state Medicaid program to cover HCBS long-term care services for
elders and people with disabilities,
7 to prevent admission into a nursing home.
iBudget Home and Community-Based Services Waiver Program
AHCA oversees the Medicaid HCBS program for individuals with specified developmental disabilities through a
federal waiver administered by APD, known as iBudget, the purpose of the waiver is to:
8
Promote and maintain the health and welfare of individuals with developmental disabilities;
Provide medically necessary supports and services to delay or prevent institutionalization; and
Foster the principles of self-determination as a foundation for services and supports.
The iBudget provides HCBS to eligible persons with developmental disabilities living at home or in a home-like
setting. 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.
9
The iBudget program allocates available funding to clients through an algorithm, providing each one an established
budget with the flexibility to choose from the authorized array of services that best meet their individual needs
within their community.
10
Medicaid Eligibility
Medicaid eligibility in Florida is determined either by DCF or the Social Security Administration (SSA) for
Supplemental Security Income (SSI) recipients. Since Medicaid is designed for low-income individuals, Medicaid
eligibility is based on an evaluation of the individual’s income and assets.
Section 1614(3) of the Social Security Act provides that an individual shall be considered to be disabled if they are
unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous
period of not less than twelve months. Further, an individual under the age of 18 shall be considered disabled if
that individual has a medically determinable physical or mental impairment, which results in marked and severe
functional limitations, and which can be expected to result in death or which has lasted or can be expected to last
for a continuous period of not less than 12 months.
Under Florida’s Medicaid State Plan, permanent and total disability is a physical or mental condition of major
significance which is expected to continue throughout the lifetime of an individual and is not expected to be
removed or substantially improved by medical treatment. It is expected to continue for a prolonged period of
disability and the eventual prognosis may be indefinite. Total disability exists when the permanent impairment, or
combination of permanent impairments, substantially precludes the individual from engaging in a useful
occupation.
7 S. 409.979, F.S. Individuals 65 years of age or older and in need of nursing facility level of care; or 18 years of age or older and eligible for
Medicaid by reason of a disability and in need of nursing facility level of care.
8 Florida Medicaid Developmental Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook, AHCA (May 2023),
available at https://apd.myflorida.com/ibudget/docs/iBudget%20Handbook%20with%20ADT%20Redesign%20Final.pdf (last visited
April 4, 2025).
9 S. 393.063(11), F.S.
10 S. 393.0662(1), F.S. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
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DCF uses the same criteria that the SSA uses to determine disability for benefits. If SSA determines an individual is
disabled, DCF adopts their disability decision. If an individual does not have a disability decision from SSA, then
DCF must obtain a disability determination based on the individual's circumstances.
11
DOEA is responsible for conducting clinical level of care evaluations under the LTC Waiver, while APD is
responsible for conducting clinical level of care evaluations under the iBudget Waiver. To be eligible for Medicaid
under 1915(c) waivers, the individual must be determined to need the level of care provided by a hospital, nursing
home, or intermediate care facility for the developmentally disabled.
12 The clinical level of care is determined
during an initial evaluation and the individual must be reevaluated at least annually.
13
Federal regulations require DCF make a redetermination of eligibility without requiring information from the
individual if it is possible to make a redetermination based on reliable information contained in the individual’s
account or obtained from another state agency or federal agency.
14 If DCF is unable to verify the individual’s
eligibility, they send the recipient a renewal notice, electronically and by mail, requesting the required information
to make an eligibility determination.
15
Between April 2023 and February 2025, approximately 534 disabled individuals lost their Medicaid coverage
16
because they failed to provide information requested by DCF to make an eligibility determination.
17 The number of
those individuals that would have still been eligible for Medicaid if they would have sent the requested information
to DCF is unknown. Over that same period of time, approximately 3,357 disabled individuals lost their Medicaid
coverage because they did not meet the income and asset eligibility requirements.
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BILL HISTORY
COMMITTEE REFERENCE ACTION DATE
STAFF
DIRECTOR/
POLICY CHIEF
ANALYSIS
PREPARED BY
Health Care Facilities & Systems
Subcommittee
15 Y, 0 N, As CS 3/27/2025 Calamas Guzzo
THE CHANGES ADOPTED BY THE
COMMITTEE:
Specified that the bill applies to Medicaid recipients enrolled in a home
and community-based services waiver program or the Long-Term Care
managed care program.
Removed the 5-year limit on continuous enrollment for disabled
individuals, making it a lifetime term of continuous enrollment.
Made the continuous enrollment apply unless information becomes
available that conclusively documents a change in the person’s
disability or economic status that would affect eligibility.
Health Care Budget Subcommittee 13 Y, 0 N 4/9/2025 Clark Smith
Health & Human Services
Committee
4/14/2025 Calamas Guzzo
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THIS BILL ANALYSIS HAS BEEN UPDATED TO INCORPORATE ALL OF THE CHANGES DESCRIBED ABOVE.
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11 Supra note 1.
12 42 C.F.R., § 441.301(b).
13 42 C.F.R., § 441.302(c).
14 42 C.F.R., § 435.916.
15 Supra note 1.
16 Includes the following categories of Medicaid that cover disabled populations: Family Related Medicaid; Long-term Care Medicaid; HCBS
Waiver Medicaid; Community Hospice Medicaid; and Medicaid for Aged and Disabled (MEDS-AD).
17 Supra note 1.
18 Id.