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 Appropriations
BILL: SB 7032
INTRODUCER: Appropriations Committee on Health and Human Services
SUBJECT: Medicaid Enrollment for Permanently Disabled Individuals
DATE: April 21, 2025
ANALYST STAFF DIRECTOR REFERENCE ACTION
Barr
McKnight
AHS Submitted as Comm.
Bill/Fav
1. Barr Sadberry AP Favorable
I. Summary:
SB 7032 provides presumptive eligibility to permanently disabled individuals receiving
Medicaid-covered institutional care, hospice, or home and community-based services and
requires the Agency for Health Care Administration (AHCA) to continue payments unless there
is a material change in the individual’s disability or economic status that affects eligibility.
The bill requires covered individuals, caregivers, or responsible parties to notify the AHCA and
the Department of Children and Families (DCF) of any change in disability or economic status.
The DCF may then conduct eligibility redeterminations and must notify the individual or
caregiver of the start and result of such redetermination.
The bill also requires the AHCA to seek federal approval to exempt permanently disabled
Medicaid-qualified individuals from annual eligibility redeterminations. The AHCA and the
DCF are required to establish a process to facilitate notification of changes impacting eligibility.
The bill will have a significant negative fiscal impact on the DCF and an indeterminate negative
fiscal impact on the Florida Medicaid Program. See Section V., Fiscal Impact Statement.
The bill takes effect July 1, 2025.
II. Present Situation:
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 the Agency for Health Care Administration (AHCA)
REVISED: BILL: SB 7032 Page 2
and financed by federal and state funds.
1 The AHCA delegates certain functions to other state
agencies, including the Department of Children and Families (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.
2 States can add benefits, with federal approval. Florida has added many optional
benefits, including prescription drugs, adult dental services, and dialysis.
3
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.
4
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 care. This federal spending
limitation creates a bias toward institutional care, and toward acute care, rather than allowing the
non-acute supports that avoid institutionalization.
1
Title 42 U.S.C. §§ 1396-1396w-5; Title 42 C.F.R. Part 430-456 (§§ 430.0-456.725) (2016).
2
S. 409.905, F.S.
3
S. 409.906, F.S.
4
S. 409.964, F.S. BILL: SB 7032 Page 3
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,
5 to prevent admission into a nursing home.
iBudget Home and Community-Based Services Waiver Program
The AHCA oversees the Medicaid HCBS program for individuals with specified developmental
disabilities through a federal waiver administered by the APD, known as iBudget. The purpose
of the waiver is to:
6
• 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.
7
The iBudget program allocates available funding through an algorithm, providing each client an
established budget with the flexibility to choose from the authorized array of services that best
meet their individual needs within their community.
8
Medicaid Eligibility
Medicaid eligibility in Florida is determined either by the 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.
5
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.
6
Agency for Health Care Administration, Florida Medicaid Developmental Disabilities Individual Budgeting Waiver
Services Coverage and Limitations Handbook (May 2023), available at
https://apd.myflorida.com/ibudget/docs/iBudget%20Handbook%20with%20ADT%20Redesign%20Final.pdf (last visited
Apr. 7, 2025).
7
S. 393.063(11), F.S.
8
S. 393.0662(1), F.S. BILL: SB 7032 Page 4
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 a permanent impairment, or a combination of permanent
impairments, substantially precludes the individual from engaging in a useful occupation.
The DCF uses the same criteria that the SSA uses to determine disability for benefits. If the SSA
determines an individual is disabled, the DCF adopts their disability decision. If an individual
does not have a disability decision from the SSA, then the DCF must obtain a disability
determination based on the individual's circumstances.
9
The DOEA is responsible for conducting clinical level of care evaluations under the LTC
Waiver, while the 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.
10 The clinical level of care is determined during an
initial evaluation and the individual must be reevaluated at least annually.
11
Federal regulations require the 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.
12 If the 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.
13
Between April 2023 and February 2025, approximately 534 disabled individuals lost Medicaid
coverage
14 because they failed to provide information requested by the DCF to make an
eligibility determination.
15 The number of individuals who may have remained eligible for
Medicaid had they submitted the requested information to the DCF is unknown. During the same
period, approximately 3,357 disabled individuals lost Medicaid coverage due to not meeting
income and asset eligibility requirements.
16
9
Department of Children and Families, House Bill 1227 Bill Analysis (Mar. 17, 2025)(on file with Senate Appropriations
Committee on Health and Human Services).
10
42 C.F.R., § 441.301(b).
11
42 C.F.R., § 441.302(c).
12
42 C.F.R., § 435.916.
13
Supra note 9.
14
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).
15
Supra note 9.
16
Id. BILL: SB 7032 Page 5
III. Effect of Proposed Changes:
Section 1 amends s. 409.904, F.S., to provide presumptive Medicaid eligibility to individuals
who are permanently disabled and receiving institutional care, hospice, or home and community-
based services, during any redetermination process.
The bill requires the Agency for Health Care Administration (AHCA) to continue payments for
these services unless a material change in the individual's disability or economic status results in
ineligibility and requires that individuals, caregivers, or responsible parties notify the AHCA and
the Department of Children and Families (DCF) of any such changes. The DCF is then
authorized to conduct a redetermination and required to notify the individual, caregiver, or
responsible party before and, at its conclusion, the results of the redetermination.
The bill requires the AHCA to seek federal approval by October 1, 2025, to exempt permanently
disabled Medicaid recipients from annual redetermination. For this exemption, the term
“permanently disabled” means that a person has been determined to be disabled under
s. 409.904(1)(a), F.S., and has had his or her qualifying disability certified by a physician
licensed under ch. 458 or ch. 459, F.S., as permanent.
In addition, the bill requires the AHCA and the DCF to develop a process to facilitate required
notifications.
Section 2 provides that the bill takes effect July 1, 2025.
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. BILL: SB 7032 Page 6
V. Fiscal Impact Statement:
A. Tax/Fee Issues:
None.
B. Private Sector Impact:
None.
C. Government Sector Impact:
The bill is expected to have a significant negative fiscal impact of $708,000 on the
Department of Children and Families to update their online Medicaid application
platform, the Florida System (ACCESS).
17 Based on an analysis of the unreserved cash in
DCF’s trust funds, the costs to the department can be absorbed within existing resources.
The bill will have an indeterminate negative fiscal impact on the Florida Medicaid
Program.
18 Because the exemption is limited to individuals with medically verified,
permanent disabilities, the potential for ineligible individuals remaining enrolled is
expected to be minimal, given the eligibility criteria and required physician certification.
However, the cost of providing continued Medicaid coverage to any ineligible individuals
within this group is indeterminate.
VI. Technical Deficiencies:
None.
VII. Related Issues:
None.
VIII. Statutes Affected:
This bill substantially amends section 409.904 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.
17
Department of Children and Families, House Bill 1227 Bill Analysis (Mar. 17, 2025)(on file with Senate Appropriations
Committee on Health and Human Services).
18
Agency for Health Care Administration, House Bill 1227 Bill Analysis (Mar. 4, 2025)(on file with Senate Appropriations
Committee on Health and Human Services. BILL: SB 7032 Page 7
B. Amendments:
None.
This Senate Bill Analysis does not reflect the intent or official position of the bill’s introducer or the Florida Senate.