Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 1 of 8 CHAMBER ACTION

Senate House

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Representative Grimsley offered the following: 1

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Amendment (with title amendment) 3

Remove lines 379-384 and insert: 4

(9)(a) The agency, in consultation with the Agency for 5 Health Care Administration, shall establish an individual 6 budget, referred to as an iBudget, demonstration project for 7 each individual served through the Medicaid waiver program in 8 Escambia, Okaloosa, Santa Rosa, and Walton Counties, which 9 comprise area one of the agency. For the purpose of this 10 subsection, the Medicaid waiver program includes the four-tiered 11 waiver system established in subsection (3) or the Consumer 12 Directed Care Plus Medicaid waiver program. The funds 13 appropriated to the agency and used for Medicaid waiver program 14 services to individuals in the demonstration project area shall 15 be allocated through the iBudget system to eligible, Medicaid-16 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 2 of 8

enrolled clients. The iBudget system shall be designed to 17 provide for enhanced client choice within a specified service 18 package, appropriate assessment strategies, an efficient 19 consumer budgeting and billing process that includes 20 reconciliation and monitoring components, a redefined role for 21 support coordinators that avoids potential conflicts of 22 interest, a flexible and streamlined service review process, and 23 a methodology and process that ensure the equitable allocation 24 of available funds to each client based on the client’s level of 25 need, as determined by the variables in the allocation 26 algorithm. 27

1. In developing each client’s iBudget, the agency shall 28 use an allocation algorithm and methodology. The algorithm shall 29 use variables that have been determined by the agency to have a 30 statistically validated relationship to the client’s level of 31 need for services provided through the Medicaid waiver program. 32 The algorithm and methodology may consider individual 33 characteristics, including, but not limited to, a client’s age 34 and living situation, information from a formal assessment 35 instrument that the agency determines is valid and reliable, and 36 information from other assessment processes. 37

2. The allocation methodology shall provide the algorithm 38 that determines the amount of funds allocated to a client’s 39 iBudget. The agency may approve an increase in the amount of 40 funds allocated, as determined by the algorithm, based on the 41 client’s having one or more of the following needs that cannot 42 be accommodated within the funding as determined by the 43 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 3 of 8

algorithm and having no other resources, supports, or services 44 available to meet those needs: 45

a. An extraordinary need that would place the health and 46 safety of the client, the client’s caregiver, or the public in 47 immediate, serious jeopardy unless the increase is approved. An 48 extraordinary need may include, but is not limited to: 49

(I) A documented history of significant, potentially life-50 threatening behaviors, such as recent attempts at suicide, 51 arson, nonconsensual sexual behavior, or self-injurious behavior 52 requiring medical attention; 53

(II) A complex medical condition that requires active 54 intervention by a licensed nurse on an ongoing basis that cannot 55 be taught or delegated to a nonlicensed person; 56

(III) A chronic co-morbid condition. As used in this sub-57 sub-subparagraph, the term “co-morbid condition” means a medical 58 condition existing simultaneously with but independently of 59 another medical condition in a patient; or 60

(IV) A need for total physical assistance with activities 61 such as eating, bathing, toileting, grooming, and personal 62 hygiene. 63

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However, the presence of an extraordinary need alone does not 65 warrant an increase in the amount of funds allocated to a 66 client’s iBudget as determined by the algorithm. 67

b. A significant need for one-time or temporary support or 68 services that, if not provided, would place the health and 69 safety of the client, the client’s caregiver, or the public in 70 serious jeopardy unless the increase is approved. A significant 71 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 4 of 8

need may include, but is not limited to, the provision of 72 environmental modifications, durable medical equipment, services 73 to address the temporary loss of support from a caregiver, or 74 special services or treatment for a serious temporary condition 75 when the service or treatment is expected to ameliorate the 76 underlying condition. As used in this sub-subparagraph, the term 77 “temporary” means lasting for a period of less than 12 78 consecutive months. However, the presence of such significant 79 need for one-time or temporary support or services alone does 80 not warrant an increase in the amount of funds allocated to a 81 client’s iBudget as determined by the algorithm. 82

c. A significant increase in the need for services after 83 the beginning of the service plan year that would place the 84 health and safety of the client, the client’s caregiver, or the 85 public in serious jeopardy because of substantial changes in the 86 client’s circumstances, including, but not limited to, permanent 87 or long-term loss or incapacity of a caregiver, loss of services 88 authorized under the state Medicaid plan due to a change in age, 89 or a significant change in medical or functional status that 90 requires the provision of additional services on a permanent or 91 long-term basis that cannot be accommodated within the client’s 92 current iBudget. As used in this sub-subparagraph, the term 93 “long-term” means lasting for a period of more than 12 94 continuous months. However, such significant increase in need 95 for services of a permanent or long-term nature alone does not 96 warrant an increase in the amount of funds allocated to a 97 client’s iBudget as determined by the algorithm. 98

99 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 5 of 8

The agency shall reserve portions of the appropriation for the 100 home and community-based services Medicaid waiver program for 101 adjustments required pursuant to this subparagraph and may use 102 the services of an independent actuary in determining the amount 103 of the portions to be reserved. 104

3. A client’s iBudget shall be the total of the amount 105 determined by the algorithm and any additional funding provided 106 under subparagraph 2. A client’s annual expenditures for 107 Medicaid waiver services may not exceed the limits of his or her 108 iBudget. 109

(b) The Agency for Health Care Administration, in 110 consultation with the agency, shall seek federal approval for 111 the iBudget demonstration project and amend current waivers, 112 request a new waiver if appropriate, and amend contracts as 113 necessary to implement the iBudget system to serve eligible, 114 enrolled clients in the demonstration project area through the 115 Medicaid waiver program. 116

(c) The agency shall transition all eligible, enrolled 117 clients in the demonstration project area to the iBudget system. 118 The agency may gradually phase in the iBudget system with full 119 implementation by January 1, 2013. 120

1. The agency shall design the phase-in process to ensure 121 that a client does not experience more than one-half of any 122 expected overall increase or decrease to his or her existing 123 annualized cost plan during the first year that the client is 124 provided an iBudget due solely to the transition to the iBudget 125 system. However, all iBudgets in the demonstration project area 126 must be fully phased in by January 1, 2013. 127 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 6 of 8

(d) A client must use all available services authorized 128 under the state Medicaid plan, school-based services, private 129 insurance and other benefits, and any other resources that may 130 be available to the client before using funds from his or her 131 iBudget to pay for support and services. 132

(e) The service limitations in subparagraphs (3)(f)1., 2., 133 and 3. shall not apply to the iBudget system. 134

(f) Rates for any or all services established under rules 135 of the agency shall be designated as the maximum rather than a 136 fixed amount for individuals who receive an iBudget, except for 137 services specifically identified in those rules that the agency 138 determines are not appropriate for negotiation, which may 139 include, but are not limited to, residential habilitation 140 services. 141

(g) The agency shall ensure that clients and caregivers in 142 the demonstration project area have access to training and 143 education to inform them about the iBudget system and enhance 144 their ability for self-direction. Such training shall be offered 145 in a variety of formats and, at a minimum, shall address the 146 policies and processes of the iBudget system; the roles and 147 responsibilities of consumers, caregivers, waiver support 148 coordinators, providers, and the agency; information available 149 to help the client make decisions regarding the iBudget system; 150 and examples of support and resources available in the 151 community. 152

(h)1. The agency, in consultation with the Agency for 153 Health Care Administration, shall prepare a design plan for the 154 purchase of an evaluation by an independent contractor. The 155 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 7 of 8

design plan to evaluate the iBudget demonstration project shall 156 be submitted to the President of the Senate and the Speaker of 157 the House of Representatives for approval not later than 158 December 31, 2010. 159

2. The agency shall prepare an evaluation that shall 160 include, at a minimum, an analysis of cost savings, cost 161 containment, and budget predictability. In addition, the 162 evaluation shall review the demonstration with regard to 163 consumer education, quality of care, affects on choice of and 164 access to services, and satisfaction of demonstration project 165 participants. The agency shall submit the evaluation report to 166 the Governor, the President of the Senate, and the Speaker of 167 the House of Representatives no later than December 31, 2013. 168

(i) The agency shall adopt rules specifying the allocation 169 algorithm and methodology; criteria and processes for clients to 170 access reserved funds for extraordinary needs, temporarily or 171 permanently changed needs, and one-time needs; and processes and 172 requirements for selection and review of services, development 173 of support and cost plans, and management of the iBudget system 174 as needed to administer this subsection. 175

(10) The agency shall develop a transition plan for 176 recipients who are receiving services in one of the four waiver 177 tiers at the time qualified plans are available in each 178 recipient’s region pursuant to s. 409.989(3) to enroll those 179 recipients in qualified plans. 180

(11) This section expires October 1, 2015. 181

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T I T L E A M E N D M E N T 185

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providing for an establishment of an iBudget demonstration 187 project by the Agency for Persons with Disabilities, in 188 consultation with the Agency for Health Care 189 Administration, in specified counties; providing for 190 allocation of funds; providing goals; providing for an 191 allocation algorithm and methodology for development of a 192 client’s iBudget; providing for the seeking of federal 193 approval and waivers; providing for a transition to full 194 implementation; providing for inapplicability of certain 195 service limitations; providing for setting rates; providing 196 for client training and education; providing for 197 evaluation; requiring a report; requiring rulemaking; 198

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