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 452
INTRODUCER: Fiscal Policy Committee; Appropriations Committee on Health and Human Services;
and Senators Harrell, and others
SUBJECT: Home Health Aides for Medically Fragile Children
DATE: April 17, 2023 REVISED:
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Looke Brown HP Favorable
2. McKnight Money AHS Fav/CS
3. Looke Yeatman FP Fav/CS
Please see Section IX. for Additional Information:
COMMITTEE SUBSTITUTE - Substantial Changes
I. Summary:
CS/CS/SB 452 creates the Home Health Aides for Medically Fragile Children program to help
ameliorate the impact of the shortage of health care workers on medically fragile children. The
bill requires the Agency for Health Care Administration (AHCA), in consultation with the Board
of Nursing (BON), to approve any training program created by a Home Health Agency (HHA)
that meets the federal standards1 for a nurse aide training program and which is meant to train
family caregivers as home health aides for medically fragile children (aide).
The bill requires that such a program consist of at least 85 hours of training in specified topics
and allows a HHA to employ a family caregiver as an aide if he or she has completed the training
program and met other specified criteria, including background screening. The bill also requires
an aide to complete HIV/AIDS and Cardiopulmonary Resuscitation (CPR) training and requires
the employing HHA to ensure that the aide has 12 hours of in-service training every 12 months.
The bill grants civil immunity to a HHA that terminates or denies employment to an aide who
fails to maintain the requirements of the section or whose name appears on a criminal screening
report.
1
42 C.F.R. 483.151-483.154 and 484.80
BILL: CS/CS/SB 452 Page 2
The bill allows the AHCA, in consultation with the BON, to adopt rules to implement the bill
and requires the AHCA to assess the program annually and to modify the Medicaid state plan
and implement any federal waivers necessary to implement the program.
The bill authorizes four full-time equivalent (FTE) positions with associated salary rate of
186,483, and $353,589 in recurring funds and $118,728 in nonrecurring funds from the Health
Care Trust Fund in Fiscal Year 2023-2024 to the AHCA to implement provisions of the bill.
The bill has an indeterminate fiscal impact on the Florida Medicaid program. See Section V of
this analysis.
The bill takes effect upon becoming law.
II. Present Situation:
Home Health Agencies
A “home health agency” (HHA) is an organization that provides home health services.2 Home
health services comprise health and medical services and supplies furnished to an individual in
the individual’s home or place of residence.3
Home health aides4 and certified nursing assistants5 (CNAs) are unlicensed health care workers
employed by a HHA to provide personal care6 to patients and assist them with the following
activities of daily living:
Ambulation;
Bathing;
Dressing;
Eating;
Personal hygiene;
Toileting;
Physical transferring;
Assistance with self-administered medication; and
Administering medications.7
2
s. 400.462(12), F.S.
3
s. 400.462(15), F.S., home health services include the following: nursing care; physical, occupational, respiratory, or speech
therapy; home health aide services; dietetics and nutrition practice and nutrition counseling; and medical supplies, restricted
to drugs and biologics prescribed by a physician.
4
s. 400.462(14), F.S., a home health aide is a person who is trained or qualified, as provided by rule, and who provides
hands-on personal care, performs simple procedures as an extension of therapy or nursing services, assists in ambulation or
exercises, assists in administering medications as permitted in rule and for which the person has received training established
by the agency, or performs tasks delegated to him or her under ch. 464, F.S.
5
s. 464.201(3), F.S., a CNA is a person who meets the qualifications of part II of ch. 464, F.S., and who is certified by the
Board of Nursing as a certified nursing assistant.
6
s. 400.462(23), F.S., defines “personal care” as assistance to a patient in the activities of daily living, such as dressing,
bathing, eating, or personal hygiene, and assistance in physical transfer, ambulation, and in administering medications as
permitted by rule.
7
Rule 59A-8.002(3), F.A.C.
BILL: CS/CS/SB 452 Page 3
Florida’s Medicaid Model Waiver
Florida’s Model Waiver is an existing waiver designed to delay or prevent institutionalization
and allow recipients to maintain stable health while living at home or in their community. The
waiver’s purpose is to provide medically necessary services to eligible children under 21 years of
age who have degenerative spinocerebellar disease and are living at home or in their community
or who are medically fragile and have resided in a skilled nursing facility for at least 60
consecutive days prior to entrance on the waiver. For the purposes of the waiver, “Medically
Fragile” is defined as an individual who is medically complex and technologically dependent on
medical apparatus or procedures to sustain life, or is dependent on a heightened level of medical
supervision to sustain life, and without such services is likely to expire without warning.
The Model Waiver provides the following services to eligible recipients:
Respite care;
Environmental accessibility adaptations; and
Transition Case Management.
The Model Waiver has a maximum capacity of 20 recipients and a reserved capacity for 15
children transitioning into the community from a skilled nursing facility.8
Private Duty Nursing Services
Currently, federal law allows Medicaid to reimburse for private duty nursing (PDN) services. 42
C.F.R. 440.80 defines PDN services as nursing services for beneficiaries who require more
individual and continuous care than is available from a visiting nurse or routinely provided by
the nursing staff of the hospital or skilled nursing facility. These services are provided:
By a registered nurse or a licensed practical nurse;
Under the direction of the beneficiary’s physician; and
To a beneficiary in one or more of the following locations at the option of the state:
o His or her own home;
o A hospital; or
o A skilled nursing facility
Florida Medicaid allows PDN to be provided to recipients under the age of 21 years who require
such services, and PDN can be provided by a HHA, a licensed practical nurse (LPN), or a
registered nurse (RN).9, 10 If the PDN is provided by a parent or legal guardian of the recipient,
Medicaid will reimburse for up to 40 hours per week, per recipient, so long as the parent or
guardian has a valid LPN or RN license and is employed by a HHA.11 However, other than those
mentioned above, services furnished by relatives as defined in s. 429.02(18), F.S., household
8
Application for a §1915(c) Home and Community Based Services Waiver, Florida Agency for Health Care Administration,
Jul. 1, 2020, available at https://ahca.myflorida.com/medicaid/hcbs_waivers/docs/Model_Waiver_Document_2020.pdf (last
visited Feb. 16, 2023).
9
59G-4.261, F.A.C.
10
Florida Medicaid, Private Duty Nursing Services Coverage Policy, Agency for Health Care Administration, Nov. 2016
available at https://ahca.myflorida.com/medicaid/review/Specific/59G-4-
261_Private_Duty_Nursing_Services_Coverage_Policy.pdf (last visited Feb. 16, 2023).
11
Id.
BILL: CS/CS/SB 452 Page 4
members, or any person with custodial or legal responsibility for the recipient are specifically not
covered under the PDN policy.12
Family Caregiver Programs in Other States
Currently, five states have family caregiver programs: Arizona, Colorado, New Hampshire,
Pennsylvania, and Indiana.13 Although each state has different specific criteria, the criteria are all
similar in that the eligible relative must be under 21 years of age, qualify for the state’s Medicaid
program, and be medically fragile or medically complex. Each state also requires the caregiver to
be trained and/or licensed as a CNA or that state’s equivalent. Once the caregiver has achieved
his or her training or licensure, he or she is required to obtain employment with a HHA and, at
that point, is eligible to be compensated by the state’s Medicaid program for services they render
to their family member.14
III. Effect of Proposed Changes:
Section 1 creates s. 400.4765, F.S., to establish the Home Health Aides for Medically Fragile
Children program. The bill amends s. 400.462, F.S., to define the following terms:
“Approved Training Program” to mean “a course of training approved by the Agency for
Health Care Administration (AHCA), in consultation with the Board of Nursing (BON),
under s. 400.4765, F.S., to train family caregivers as home health aides for medically fragile
children.”
“Eligible Relative” to mean “with respect to the home health aide for medically fragile
children program under s. 400.4765, F.S., a person 21 years of age or younger who is eligible
to receive continuous skilled nursing or skilled nursing respite care services under the
Medicaid program and is a relative of a home health aide for medically fragile children.”
“Family Caregiver” to mean “a person providing or intending to provide significant personal
care and assistance to an eligible relative 21 years of age or younger who has an underlying
physical or cognitive condition that prevents him or her from safely living independently.”
“Home Health Aide for Medically Fragile Children” to mean a family caregiver who meets
the qualifications specified in s. 400.4765, F.S.; performs tasks delegated to him or her under
chapter 464, F.S., while caring for an eligible relative; and provides care and assistance to an
eligible relative relating to:
o Activities of daily living, such as those associated with personal care, maintaining
mobility, nutrition and hydration, toileting and elimination, assistive devices, and safety
and cleanliness.
o Data gathering.
o Reporting abnormal signs and symptoms.
o Patient socialization and reality orientation.
o Cardiopulmonary resuscitation and emergency care.
o Residents’ or patients’ rights.
o Documentation of services.
12
Id.
13
Team Select Home Care, Program Locations, available at https://tshc.com/states-where-the-program-is-available/ (last
visited Feb. 20, 2023).
14
Team Select Home Care, Program Locations, available at https://tshc.com/states-where-the-program-is-available/ (last
visited Feb. 20, 2023).3
BILL: CS/CS/SB 452 Page 5
o End-of-life care.
o Postmortem care.
o Infection control.
o Safety and emergency procedures.
o Hygiene, grooming, and toileting.
o Skin care and pressure sore prevention.
o Nutrition and hydration.
o Wound care.
o Portable oxygen use and safety and other respiratory procedures.
o Tracheotomy care.
o Enteral care and therapy.
o Peripheral intravenous assistive activities and alternative feeding methods.
o Tasks delegated to the family caregiver under ch. 464, F.S.
Section 2 authorizes Home Health Aides for Medically Fragile Children (aides) to perform
certain tasks delegated by a registered nurse, including medication administration, and requires
licensed Home Health Agencies (HHAs) to ensure that aides providing such services are
adequately trained to perform these tasks.
Section 3 requires HHAs to ensure that each aide employed by or under contract with the HHA
is adequately trained to perform the tasks of a home health aide in the home setting and prohibits
a HHA from requiring an aide to repay or reimburse the HHA for costs associated with the
training program established under the bill.
Section 4 requires the AHCA, in consultation with the BON, to approve a training program
created by a HHA that meets federal requirements15 and that will train family caregivers as aides
to provide trained nursing services to eligible relatives. The training program must require a
family caregiver to complete 85 hours of training, including, but not limited to:
A minimum of 40 hours of theoretical instruction, offered in various formats and times of
day, in nursing, including, but not limited to, instruction on all of the following:
o Person-centered care.
o Communication and interpersonal skills.
o Infection control.
o Safety and emergency procedures.
o Assistance with activities of daily living.
o Mental health and social service needs.
o Care of cognitively impaired individuals.
o Basic restorative care and rehabilitation.
o Patient rights and confidentiality of personal information and medical records.
o Relevant legal and ethical issues.
A minimum of 20 hours of skills training on basic nursing skills, including, but not limited
to:
o Hygiene, grooming, and toileting.
o Skin care and pressure sore prevention.
o Nutrition and hydration.
15
42 C.F.R. 483.151-483.154 and 484.80
BILL: CS/CS/SB 452 Page 6
o Measuring vital signs, height, and weight.
o Safe lifting, positioning, and moving of patients.
o Wound care.
o Portable oxygen use and safety and other respiratory procedures.
o Tracheostomy care.
o Enteral care and therapy.
o Peripheral intravenous assistive activities and alternative feeding methods.
o Urinary catheterization and ostomy care.
At least 16 hours of clinical training under direct supervision of a licensed registered nurse.
The bill exempts family caregivers who have graduated from an accredited nursing school but
have not yet taken the state licensure exam from the requirement to take the training.
In addition to the required training, a family caregiver must care for an eligible relative;
demonstrate a minimum competency to read and write; pass a background screening pursuant to
s. 400.512, F.S., except that the AHCA must waive this requirement if the family caregiver has
passed a background screening pursuant to ss. 400.512 or 400.809, F.S., within the previous 90
days and the caregiver’s results are not retained in the Care Provider Background Screening
Clearinghouse.16
If a family caregiver allows 24 consecutive months to pass without performing any nursing-
related services for an eligible relative, the family caregiver must recomplete the training
program prior to serving as an aide.
After becoming an aide, he or she must complete an HIV/AIDS training course and maintain a
certificate in cardiopulmonary resuscitation (CPR). Additionally, the HHA employing the aide
must ensure that he or she completes 12 hours of in-service training during each 12-month period
as a condition of employment. The bill specifies that the HIV/AIDS training may count toward
the 12 hours of training and that the HHA must maintain documentation demonstrating
compliance with this requirement.
The bill grants civil immunity to a HHA for terminating or denying employment to an aide who
fails to maintain the requirements of the bill or whose name appears on a criminal screening
report of the Florida Department of Law Enforcement. The bill also grants immunity from a
cause of action and monetary liability to any licensed facility or the facility’s governing board,
medical staff, disciplinary board, agents, investig