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 Fiscal Policy
BILL: CS/CS/SB 1084
INTRODUCER: Fiscal Policy Committee; Appropriations Committee on Health and Human Services and
Senator Trumbull
SUBJECT: Pilot Program for Individuals with Developmental Disabilities
DATE: April 26, 2023 REVISED:
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Brown Brown HP Favorable
2. Gerbrandt Money AHS Fav/CS
3. Brown Yeatman FP Fav/CS
Please see Section IX. for Additional Information:
COMMITTEE SUBSTITUTE - Substantial Changes
I. Summary:
CS/CS/SB 1084 creates s. 409.9855, F.S., to establish a Medicaid long-term care managed care
pilot program in certain counties to integrate health care services, long-term care services, and
home and community-based services for persons with developmental disabilities. The pilot
program will be available, on a volunteer basis, to Medicaid eligible individuals on the iBudget
waitlist.
The bill is likely to have a significant negative fiscal impact. Neither the Agency for Health Care
Administration (AHCA), which operates the state’s Medicaid program, nor the Agency for
Persons with Disabilities, which administers the iBudget Wavier, have submitted an estimate of
the bill’s potential fiscal impact. See Section V. of this analysis.
The bill takes effect upon becoming a law.
II. Present Situation:
The Florida Medicaid Program
Florida Medicaid is the health care safety net for low-income Floridians. The national Medicaid
program is a partnership of federal and state governments established to provide coverage for
BILL: CS/CS/SB 1084 Page 2
health services for eligible persons. Florida’s program is financed through state and federal
funds.1
The Agency for Health Care Administration (AHCA) is the single state agency responsible for
the administration of the Florida Medicaid program, authorized under Title XIX of the Social
Security Act (SSA).2 This authority includes establishing and maintaining a Medicaid state plan
approved by the federal Centers for Medicare & Medicaid Services (CMS) and maintaining any
Medicaid waivers needed to operate the Florida Medicaid program as directed by Florida
Statute,3 the General Appropriations Act (GAA), and other legislation accompanying the GAA.
A Medicaid state plan is an agreement between a state and the federal government describing
how that state administers its Medicaid programs. The state plan establishes groups of
individuals covered under the Medicaid program, services that are provided, payment
methodologies, and other administrative and organizational requirements. State Medicaid
programs may request from CMS a formal waiver of the requirements codified in the SSA,
which provides states flexibility in providing services not afforded through their Medicaid state
plan.
Statewide Medicaid Managed Care
In Florida, a large majority of Medicaid recipients receive their services through a managed care
plan contracted with the AHCA under the Statewide Medicaid Managed Care (SMMC)
program.4 Other recipients who are not eligible for managed care, are not subject to mandatory
managed care enrollment, or are not yet enrolled in a plan, are provided services directly from
health care practitioners or facilities, and in those cases, providers are paid on a fee-for-service
basis.
SMMC has three components:
 Managed Medical Assistance (MMA), under which the AHCA makes payments for primary
and acute medical treatments and related services using a managed care model;
 Long-term Care Managed Care (LTCMC), under which the AHCA makes payments for
long-term care, including home and community-based services, using a managed care model;
and
 The Medicaid Prepaid Dental Health Program (Prepaid Dental), under which the AHCA
makes payments for dental services for children and adults using a managed care model.
SMMC benefits are authorized through federal waivers and are specifically required by the
Florida Legislature in ss. 409.973 and 409.98, F.S. SMMC benefits cover primary, acute,
preventive, behavioral health, prescribed drugs, long-term care, and dental services. Section
409.973, F.S., specifies the minimum services that must be provided by managed care plans:
1
Section 20.42, F.S.
2
Section 409.963, F.S.
3
See parts III and IV of ch. 409, F.S.
4
As of January 31, 2023, Florida Medicaid’s total enrollment comprised 5,696,638 persons. Eighty-seven percent were
enrolled in a Medicaid managed care plan. See:
https://ahca.myflorida.com/medicaid/Finance/data_analytics/enrollment_report/docs/ENR_202301.xls (last visited March 9,
2023).
BILL: CS/CS/SB 1084 Page 3
Managed Care Plan Benefits5
Advanced practice registered nurse services Medical supplies, equipment, prostheses, and
orthoses
Ambulatory surgical treatment center services Mental health services
Birthing center services Nursing care
Chiropractic services Optical services and supplies
Donor human milk bank services Optometrist services
Early periodic screening diagnosis and Physical, occupational, respiratory, and
treatment services for recipients under age 21 speech therapy services
Emergency services Physician services, including physician
assistant services
Family planning services and supplies. Podiatric services
Pursuant to 42 C.F.R. s. 438.102, plans may
elect to not provide these services due to an
objection on moral or religious grounds, and
must notify the agency of that election when
submitting a reply to an invitation to negotiate
Healthy start services, except as provided in s. Prescription drugs
409.975(4)
Hearing services Renal dialysis services
Home health agency services Respiratory equipment and supplies
Hospice services Rural health clinic services
Hospital inpatient services Substance abuse treatment services
Hospital outpatient services Transportation to access covered services
Laboratory and imaging services
Florida Medicaid does not cover all low-income Floridians. Current eligibility prioritizes low-
income children, disabled persons, and elders, and sets income eligibility by reference to the
annual federal poverty level. For some groups, clinical eligibility provisions apply, as well.
The Florida Medicaid program covers:6
 More than 5.5 million low-income individuals, including approximately 2.5 million children,
or 54 percent of the children in Florida;
 More than 54 percent of the births occurring in Florida in calendar year 2020; and
 More than 60 percent of the nursing home days in Florida.
Types of Comprehensive Medicaid Managed Care Plans
Comprehensive services in SMMC are managed by two types of managed care plans: traditional
managed care organizations and provider service networks (PSNs). Traditional managed care
organizations are usually health insurers or health maintenance organizations (HMOs). PSNs are
managed care plans that are owned or are majority-controlled by health care providers, such as
physician groups or hospitals.
5
Section 409.973, F.S.
6
Agency for Health Care Administration, Presentation to the Senate Health Policy Committee, Jan. 23, 2023.
BILL: CS/CS/SB 1084 Page 4
All managed care plans in SMMC, including PSNs, are reimbursed as prepaid plans. That is,
they are paid capitated rates (prospective, per-member, per-month payments) by the AHCA in
advance for any particular month and are expected to provide medically necessary services to
their respective members during that month, using the dollars within that month’s capitation.
Medically necessary services are required to be provided regardless of whether the capitation
includes all the dollars necessary to provide those services.7
The AHCA contracts with managed care plans on a statewide and regional basis, in sufficient
numbers to ensure choice. The cyclical Medicaid procurement process ensures plans offer
competitive benefit designs and prices. In addition, plans compete for consumer choice. That is,
while Medicaid requires a basic benefit package, and regulates the adequacy of plans’ provider
networks, plans can add to their benefit packages and offer provider networks attractive to
Medicaid recipients when choosing a plan.
The AHCA began the next procurement process in 2022 for implementation in the 2025 plan
year and released the re-procurement solicitation documents on April 11, 2023.8
Medicaid Long-Term Care
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 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
prevent institutionalization.
Florida obtained federal waivers to allow the state Medicaid program to cover other kinds of
long-term care services for elders and people with disabilities, to prevent admission into a
nursing home. The Medicaid Long-term Care Waiver provides services to eligible individuals
age 18 or older who need long-term services and supports, including individuals over the age of
18 with a diagnosis of cystic fibrosis, AIDS, or a traumatic brain or spinal cord injury. The Long-
term Care Waiver is designed to delay or prevent institutionalization and allow waiver recipients
to maintain stable health while receiving services at home and in the community. Individuals in
the program may also be served in a nursing facility setting. The Long-Term Care Waiver is a
capitated, managed care program.
Section 409.98, F.S., specifies the non-institutional, often non-acute, long-term care benefits that
must be provided by the long-term care managed care program:
7
See s. 409.968(1) and (2), F.S.
8
Agency for Health Care Administration, Presentation to the Senate Health Policy Committee, Jan. 23, 2023.
BILL: CS/CS/SB 1084 Page 5
SMMC Long-Term Care Mandatory Benefits
Services provided in an ALF Physical therapy
Hospice services Intermittent and skilled nursing
Adult day care Medication administration
Personal care Medication management
Home accessibility adaption Nutritional assessment and risk reduction
Behavior management Caregiver training
Home-delivered meals Respite care
Case management Personal emergency response system
Occupational therapy Transportation
Speech therapy Medical equipment and supplies
Respiratory therapy Nursing Facility Care Services
Medicaid Home and Community-Based Waiver for Persons with Developmental
Disabilities
Under federal law, fee-for-service Medicaid provides coverage for health care services to cure or
ameliorate diseases. Generally, Medicaid does not cover services that will not cure or mitigate a
medical diagnosis. However, people with developmental disabilities, while certainly requiring
traditional medical services, need other kinds of services to maintain their independence and
avoid institutionalization. Home and community-based services (HCBS) can be provided to
assist people with developmental disabilities with activities of daily living which enables them to
live in their homes or communities, rather than moving to a facility for care.
To obtain federal Medicaid funding for HCBS, Florida obtained a Medicaid waiver.9 This allows
coverage of non-medical services to avoid institutionalization and allows the state to limit the
scope of the program to the number of enrollees deemed affordable by the state. In this way, the
HCBS waiver is not an entitlement; it is a first-come, first-served, slot-limited program.
The HCBS waiver, known as iBudget Florida, serves eligible10 persons with developmental
disabilities. 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. 11
The Agency for Persons with Disabilities (APD) administers the iBudget program with the stated
purpose of:
9
Florida Developmental Disabilities Individual Budgeting Waiver (0867.R02.00), March 4, 2011, authorized under s. 1915b
of the Social Security Act.
10
The HCBS waiver retains the Medicaid requirement that enrollees be low-income, but measures only the developmentally
disabled person’s income; not the income generated by the whole household.
11
Section 393.063(12), F.S.
BILL: CS/CS/SB 1084 Page 6
 Promoting and maintaining the health and welfare of eligible individuals with developmental
disabilities.
 Providing medically necessary supports and services to delay or prevent institutionalization.
 Fostering the principles of self-determination as a foundation for services and supports.12
Section 393.066 (3), F.S., specifies that community-based services offered through the iBudget
must include the following medically necessary services to prevent institutionalization:
Home and Community-Based Services13
Adult Day Training Respite Services
Family Care Services Social Services
Guardian Advocate Referral Services Physical, Occupational, Respiratory, and
Speech Therapy
Medical/Dental Services Supported Employment
Parent Training Supported Living
Personal Care Services Behavioral Services
Recreation Transportations
Residential Facility Services Residential Habilitation
Under the broad service categories specified in s. 393.066(3), F.S., the APD offers 26 supports
and services delivered by contracted service providers to assist individuals to live in their own
homes or the community.14 These 26 services include:
 Adult day training.
 Behavioral analysis services.
 Behavior assistant services.
 Companion services.
 Consumable medical supplies.
 Dietician services.
 Durable medical equipment and supplies.
 Environmental accessibility and adaptations.
 Occupational therapy.
 Personal emergency response systems.
 Personal supports.
 Physical therapy.
 Prevocational service.
 Private duty nursing.
 Residential habilitation, including the following levels:
o Standard level.
o Behavior-focused level.
o Intensive-behavior level.
o Enhanced-intensive-behavior level.
12
Agency for Health Care Administration, Developmental Disabilities Individual Budgeting Waiver Services Coverage and
Limitations Handbook, September 2021.<