Subject: Urgent – iBudget assault on providers

August 13, 2011
Dear members and friends,
The workshop on the Medwaiver iBudget Handbook on August 9th was a bit of a surprise, there was little or no advanced warning about it.  There are several changes in the handbook, and we strongly suggest that if you are a Medwaiver provider, if you work for a Medwaiver provider, or if you are thinking of becoming a provider, you go to the link and review the manual for yourself.  It is located at:, click on the ibudget handbook.
We would also suggest you have others, like your consumer’s advocates, look at it as well.  Feedback must be received by AHCA by 5:00 pm on Tuesday, August 16th.  Please submit feedback by Sunday evening to, in order to allow time to consolidate the information. If your agency belongs to Florida ARC or FARF, you may also want to express your concerns to them, or email your comments directly to (or fax: 850.414.1721 to Susan’s attention).  Please do not read this and send back a general response saying “I don’t like this”, or something similar.  Read the manual and give specific questions or feedback with page references!  The handbook process should also include a hearing before it is adopted, but keep in mind October is the projected time ibudget will start in the Tallahassee area.  Please forward this email to as many providers as you can, there is not much time to respond.
The changes of greatest concern to behavior analysis providers at this point seem to be:
Changes to the definition of “Agency”, an agency is now defined as: (Page 3-8) “An agency provider is a business or organization enrolled to provide a waiver service(s) that has four or more staff employed to carry out the enrolled service(s).”  Also, contractors are prohibited, staff must be EMPLOYEES.
Providers required to submit service logs shall at a minimum do so via the client central record system as follows; For services that are billed at the daily or quarter hour rate;
Supplies and equipment; and assessments – within 15 calendar days after the date on which services were rendered. For monthly rates – within 15 days after the month ends.  You will not be able to bill until all paperwork is entered into the system. ADTs (and maybe other services) can only bill once a month.  
Training with changes. (Starts on 3-1) Mandatory training for all staff would include:
1. The iBudget Florida waiver program: The iBudget Florida pre-service training will include brief introductions on subjects including; promoting choice, person centered approaches, incident reporting procedures, HIPAA, recognition of abuse, neglect and exploitation, domestic violence and sexual assault, and health and safety responsibilities
2. CPR/ First Aid (CPR must be taught via classroom setting by a trainer certified by either the American Heart Association or the Red Cross. Online CPR training is not acceptable training to meet this requirement)
3. iBudget Florida Coverage and Limitations Handbook
4. HIV/AIDS and infection control
5. Zero Tolerance (must be received by all agency employees prior to providing direct service and shall be completed at least once three years)
6. Medication Administration: Chapter 65G-7, Florida Administrative Code
It is the responsibility of the provider to ensure that training which carries an expiration date (CPR/First Aid, HIV/ AIDS, Infection Control and HIPAA) is received prior to the expiration date to avoid any lapse in certification.
Changes to ADT include: (Page 4-10) 1:3 and 1:1 staffing ratios require that the individual meet criterion for Behavior Focus or Intensive Behavioral ResHab. (From Page C-3) “At all times when individuals are present, a minimum of a least one staff member or 50 percent of all staff at the facility (whichever is greater), must have been trained on Reactive Strategies and Medication Administration.”  
ResHab – (Page 4-47) IBResHab qualifications includes significant behavioral events within the past 6 months.  If a consumer is in a highly prostheticized environment, and they haven’t had a major even in the past six months because of lots of staff pre-crisis intervention, they may lose IB designation.  Also, IB ResHab requires a BCBA Level I as clinical director of the IB program.
Changes to Behavior Analysis – (Page 4-81)There is a lot of wording regarding training caregivers such as “Training for parents, caregivers and staff is also an element of the services to ensure maximum effectiveness of the services and because these persons are integral to the implementation or monitoring of a behavior analysis services plan.”  The problem is, those of us who work with adults may be working with individuals who do not have a caregiver to train.  It is inappropriate to ask the city bus driver or the consumer’s employer to implement a behavior program.  Also, with the high turnover of support staff, training PCAs, Respite Providers, In Home Support Personnel, siblings, ADT staff, etc., we are unable to realistically provide an environment where the staff and primary caregivers are trained.
Changes to Behavior Assistant  – (Page 4-84) These services are now a travesty.  Originally designed to provide a behaviorally-trained paraprofessional to implement behavior programming to individuals with challenging behaviors, they are now defined as: “The primary role of the BAS provider is to assist the Behavior Analyst or provider licensed under Chapter 490 or 491, F.S. in training paid and unpaid caregivers for the service recipient in the consistent and accurate implementation of the BASP and recording of related data. Unlike other services, the BAS provider’s focus is more on working with the caregivers to provide them with the skills to execute the procedures as detailed in the BASP, rather than, the BAS provider intervening directly with the service recipient.”  It goes on to state that the Behavior Assistant can work with consumers for a “brief” period, but then must focus on transferring the intervention to others.  Obviously, this is problematic when one is working with an adult, a family with several other small children, or with elderly parents who may have difficulty implementing a behavior program with an aggressive individual.  Services are limited to 8 hours a day, services for 6 hours or more a day require monthly LRC approval, or as “deemed appropriate” by the LRC.  Assistants are required to have 2 hours of supervision by a certified behavior analyst or 490/491 licensed individual per month.  Supervision is not defined (ie: in the presence of the consumer, privately in-office, etc).  Also, no indication if the supervision is billable for either party.  
Transportation – Fifteen-passenger vans that are not lift-equiped cannot transport more than 10 individuals.
Recoupment – There are draconian recoupment policies for late paperwork for the following services: adult day training, non-residential support services, residential habilitation, supported employment and supported living coaching. (Page 5-3)
Behavior Analysis Documentation:
Copy of claim(s) submitted for payment;
Copy of service log;
Copy of assessment report, when as assessment report has been requested
Quarterly summary of monitoring including who, what, when and where of the monitoring events; or other content as required by the Agency.
Quarterly summary of each quarter of the support plan year. The fourth quarterly summary also serves as the annual report and must include a summary of the previous three quarters  
• Behavior analysis service plan and services provided including graphic display of acquisition and reduction behaviors related to implementation of the behavior analysis service plan, and
• Dated evidence of LRC reviews, approval and recommendations specific to target behaviors and the behavior plan, as required and consistent with 65G-4.010, F.A.C.,
Behavior Assistant Documentation –
1. Copy of claim(s) submitted for payment;
2. Copy of service log;
3. Quarterly summary of monitoring of program implementation including the who, what, when, and where of the monitoring events;
4. Quarterly summary of each quarter of the support plan year. The fourth quarterly summary also serves as the annual report and must include a summary of the previous three quarters
5. Copy of the behavior analysis service plan must be in the recipient’s file prior to claim submission.
5. Monthly data displays;
6. A record of the LRC review of the behavior services plan and data displays must be provided if the targeted reduction behaviors meet the requirements identified in 65G-4.009, F.A.C.; and
7. A record of the LRC review of the behavior services plan and data displays must be provided if more than 65 quarter hours of behavior assistant services are approved daily.
Various Appendices identify the specific training requirements, look them over!
Sorry to be the bearers of bad news, but we encourage you to read the manual carefully and give your input.