This is an e-mail I received from Florida Association of Support Coordinators (FASC).


10% Reduction Exercise


  • Reduction of $707,377 in General Revenue from APD headquarters operations.
  • Reduction of $733,282 in General Revenue from the area offices.
  • Reduction of $182,835 from the Developmental Services Institutions.
  • Reduction of $1,556,131 in contracted services, room and board, prescriptions, etc.
  • Reduction of $1,774,056 in services to clients.  (Those not on the waiver.)
  • Reduction of $957,409 in institutional forensic staffing.
  • Reduction of $1,724,687 in institutional staffing.
  • Reduction of $1,864,185 by combining consumable and durable equipment purchasing on the waiver by regional purchasing contracts.
  • Reduction of $4,000,000 by eliminating behavior assistance service in standard and behavior focus group homes.
  • Reduction of $3,286,586 by reduction in accounts for persons in Consumer Directed Care by 10%.
  • Reduction of $9,685,154 by consolidating services…day training, supported employment, supported living, in-home supports, companion, and respite.  This would represent an 8% reduction in current expenditures.
  • Reduction of $11,198,958 by capping Tier One to $120,000 per year.
  • Reduction of $51,455,374.  This option was not recommended as it would reduce current services such as meaningful day and in-home supports and would result in institutionalization of individuals.


Budget Request


  • Request for $2,400,000 for the transition of 60 people from Gulf Coast to community.  (Continue plans to close Gulf Coast by 6/30/2010.  Average expenditure of those transferred from Gulf Coast has been running around $79,293.00 each.  The requested funds are for six months of funding.)
  • APD requested $234,925 to support expansion of CDC+.  People transferring to CDC+ must give up 8% of their funding so this request will be offset by cuts to the Waiver program.
  • There is a request of $4,500,000 for people on the waitlist.  These would be short term or one time services such as respite. 
  • There is a budget request of $30,000,000 to serve 2,200 people.  300 of those they are requesting services for are children in the DCF child welfare system that Florida law has required priority of funding for.  Remaining funds would go to fund some in crisis on the waitlist.  (734 children/people would go into Tier 4 and 1,466 others would probably go into Tiers 3, 2 and 1.)
  • A request for $6,886,500 to offset the projected deficit in the Waiver for 2009-2010.
  • A request for $31,932 for salary and benefit from to complete transfer of positions from DCF.
  • Request for transfer of five positions from the Institutions to APD Program and Compliance budget. 
  • Request for two positions that were in the Institution budget, (but located at Central Office) to the Central Office budget.
  • Request of $138.979 to continue 3 legal positions, some of which are currently associated with Gulf Coast Center.
  • Request of $728,193 in funding for legal staff.  Some of the funds are requested as a transfer from DCF, which at times have a conflict of interest due to representation of foster children.  In the past year, APD has less than 1,000 fair hearings.  It is anticipated that Agency attorneys will represent the Agency in over 5,000 hearings in the coming year.   The Agency anticipates over 5,000 fair hearings, 55 tort actions, 34 garnishments, 7 arbitrations, 14 unemployment compensation hearings, 990 forensic cases, 184 dependency cases, 9 appeals, 59 guardianships and other proceedings.
  • Request of $729,524 ($658,603 non reoccurring funds) for core technology infrastructure. 
  • Request of $270,750 from AHCA contingent upon receiving a grant from The Department of Health for maintenance of a registry for special needs.
  • Request of $78,657 for position to perform Information Security Management.
  • Request of $184,050 for three positions in the Office of Inspector General. 


Notes of Interest

The anticipated split for the Waiver program is based on 55.13% federal, 44.87 percent from General Revenue funds.


APD and DCF have had to request a budget transfer item of approximately 3 million for supported living subsidies due to the fact that the current source of the funds cannot be used for supported living subsidies.  1,700 people receive this subsidy.  If the transfer is not approved, the result will be termination of the subsidy.


$13,433,384 dollars were certified forward. 

Thanks to Wonderful Aaron Nangle from WaiverProvider.com .  Here is a simplier, more user friendly explanation of the 4-tier Waiver.  If you haven’t connected with WaiverProvider.com , be sure and check out his fine on-line newsletter.  You can subscribe to the newsletter; and it will be sent to you automatically.   By the way, to hopefully simplify,  this is a three entry post.  You will find part 2 and part 3 after this post.  Nangle gets all the credit for all the work.

Tier 4        $14,792


(Most Kids and People Who Only Have The FSL Waiver)


  Right Now Has-  The FSL/ Florida Supported Living Waiver. 


– Is under 22, AND lives in a family home. 


– Is a dependent child who lives in a group home setting.



*** Most kids will be in this tier.  See other tiers for intensive behavior and/or medical needs.  ****







Tier 3                $35,000


Is 21 or Older AND (must meet one)

-Lives in a group home setting.

-Gets in home supports in their OWN HOME. (supported living environment)

– Gets Personal Care Assistance (PCA) at the MODERATE rate.

– Gets Skilled or Private Duty Nursing.

– Gets A Therapy Service (Occupational Therapy, Physical Therapy, Speech Therapy, or Respitory Therapy. 



– Gets Behavior Analyst and/or behavior assistant service and is 22 or older. 


– Gets More than 60 hours a month of behavior analyst and/ or behavior assistant service.

Tier 2       $55,000


– Gets Residential Habilitation services 5 or more hours per day.




  Gets Supported Living AND  6 or more hours per day of in home supports. 









Tier 1     No Cap At This Time


NEEDS CAN NOT BE MET IN OTHER TIERS!  (essential for avoiding institutionalization)


Behavioral Needs That exceed what can be met in the other tiers.   (A substantial risk of harm to themselves or others.)


Residential Habilitation At:

   – Behavior Intensive

     Behavior Focus

   – Standard at Extensive 1 or Higher

   – Special Medical Home Care

   – Nursing. 


Tiers will be determined after considering the following:  QSI score, Service Needs, Age and Current Living Setting, and Availability of Natural Resources. 


Tiers Change if there is a significant change in circumstances and/or condition that affects health, safety, and/or  well being. 

 These are talking points that came on APD stationary via Aaron Nangle.  Not too easy to understand but you can see how much work Nangle had to do make it clear for us.



Talking Points on Tiers


  • The Agency for Persons with Disabilities (APD) is committed to protecting the health and safety of the people it serves by helping them receive the services they need.
  • Over the past year, there have been many changes to the Medicaid waiver program.  The changes have been difficult for both APD customers and employees.
  • Last year, the Legislature changed the law to require a four-tier waiver system for individuals receiving Medicaid Waiver services from APD. 
  • The Legislature created four waiver tiers for people who receive services under the Developmental Disabilities Waiver, the Family and Supported Living Waiver, or the Consumer Directed Care Program.  The Legislature also created eligibility criteria for the waivers. 
  • APD is developing a rule that will help assign customers to a tier as required by the Legislature.
  • APD is currently identifying the likely tier for each client.  APD plans to notify customers of their tier assignment by the end of May.  
  • The Legislature imposed annual limits on how much the state will spend for services for people in three of the tiers. 
  • The Legislative limits are:  Tier 1 – no limit; Tier 2 – $55,000; Tier 3 – $35,000; and Tier 4 – $14,792.
  • Most people will not be affected by their tier assignment.  But for some people, the tier assignment will mean that the state will not be able to pay as much for services as it has in the past. 
  • If a customer’s Tier Waiver assignment results in a spending limit lower than the amount that is annually spent on services, he or she should work with their support coordinator to prioritize the services in his or her cost plan so they do not exceed the limit and that the services most important are supported. 
  • APD is supplying waiver support coordinators with information on how to help customers in prioritizing their cost plan to stay within the spending limit, if necessary. 
  • APD plans to implement the Tiers July 1, 2008.
  • The Agency for Persons with Disabilities has additional information about the Tier Waivers on its Web site (http://apd.myflorida.com).  Contact your Waiver Support Coordinator or the local APD office if you have questions.

Proposed Specific Criteria for Waivers

Tier 1 Waiver (Currently the Developmental Disabilities Waiver)

·      The individual has intensive medical or adaptive needs that are essential for avoiding institutionalization, and the individual’s needs cannot be met in Tier Waivers 2, 3, or 4; or

·      The individual has behavioral problems that are exceptional in intensity, duration, or frequency and present a substantial risk of harm to themselves or others, and the individual’s needs cannot be met in Tier Waivers 2, 3, or 4.


Tier 2 Waiver (A new waiver capped at $55,000 a year)

·      The customer’s service needs include placement in a licensed residential facility and authorization for greater than five hours per day of residential habilitation services; or

·      The client is in supported living and is authorized to receive more than six hours a day of in-home support services.


Tier 3 Waiver (A new waiver capped at $35,000 a year)

·      The customer resides in a licensed residential facility and is not eligible for the Tier One Waiver or Tier Two Waiver; or

·      The client is 21 or older, resides in their own home and receives live-in, In-Home Support Services, and is not eligible for Tier One Waiver or Tier Two Waiver; or

·      The customer is 21 or older and authorized to receive Personal Care Assistance services at the moderate level of support as defined in the Developmental Disabilities Handbook; or

·      The client is 21 or older and authorized to receive Skilled or Private Duty Nursing Services and not eligible for the Tier One Waiver or Tier Two Waiver; or

·      The customer is 22 or older and is authorized to receive services of a behavior analyst and/or a behavior assistant.

·      The client is under the age of 22, and authorized to receive the combined services of a behavior analyst and/or a behavior assistant for more than 60 hours a month and is not eligible for the Tier One Waiver or Tier Two Waiver.

·      The customer is 21 or older and authorized to receive at least one of the following services: Occupational Therapy, Physical Therapy, Speech Therapy, or Respiratory Therapy.


Tier 4 Waiver (Formerly the Family and Supported Living Waiver, capped at $14,792 a year.) 

·      Clients who are currently assigned to receive services through the Family and Supported Living Waiver unless there is a significant change in condition or circumstance.

·       The total budget in a cost plan year for each Tier Four Waiver client shall not exceed $14,792 per year.

·      Customers who are not eligible for assignment to the Tier One Waiver, Tier Two Waiver, or Tier Three Waiver shall be assigned to the Tier Four Waiver.

·      Customers who are under the age of 22 and residing in their own home or the family home.

·      Clients who are dependent children who reside in residential facilities licensed by the Department of Children and Families.




Modified April 24, 2008

Again, thanks to Aaron Nangle from WaiverProvider.com , here is a continuation of his explanation of the four-tier waiver.  Be sure and visit his website and thank him for all this hard work.


The first column is based on Tier 4 plans,

The second on Tier 3 plans

The third on tier 2 plans. 

Notice that many go over, with just the basics. 


Sample Cost Plans

– Based On Limited Support Coordination of $67.50 Month

– Based on Transportation at $10.00 Per Trip

– Based on Agency Rates, With No Geographic Factors. 

– Maximum Respite is 300 hours per year. 

Add $810.00

For Full Support Coordination

Add $2016.00

For 1-5 ADT. 

Add $3885.44

 For 1 hour per week of Level 2 Behavior Services. 

Look At These Cost Plans.  What happens when we have to add diapers, medication review, dental, full support coordination, or behavior therapy?

1.  Limited S.C.

2.  Maximum Respite

3.  ADT 5x Week

4.  Transportation

Total Cost = $16,710.00

1.  Limited S.C.

2.  Companion 5 x week



Total Cost  = $23,461.20

1.  Limited S.C.

2.  SL Coach, 20 hours month

3.  SE Coach, 20 hours month


Total Cost = $18,608

1.  Limited S.C.

2.  PCA, 2 Hours per day

3.  ADT 5x Week (Moderate)

4.  Transportation

5.  Maximum Respite

Total = $31,072.88

1.  Limited S.C.

2.  ADT, 5x week

3.  Transportation

4.  In home supports, 3 hours per day.

5.  SL Coach, 20 hours month

Total = $38,246.40

1.  Limited S.C.

2.  Companion 5x week

3.  PCA, 3 hours day



Total = $41,981.52

1.  Limited S.C.

2.  Moderate Res. Hab.

3.  ADT 5x Week

4.  Transportation

Total Cost =  $54,432.00

1.  Limited S.C.

2.  Moderate Res Hab.

3.  Companion 5x week


Total Cost = $65,083.20

1.  Limited S.C.

2.  In Home Supports, Day Rate, 365 days year

3.  SL Coach 20 hrs month

Total Cost = $54,939.05


When HIPPA was passed by the Senate and House of Representatives and signed into law by the President, there was one aim and that was to protect the privacy of patients’ information that might be transmitted over the internet or faxed.  The law clearly states that any patient information transmitted or transferred through an electrical process (fax or internet) is protected by federal law. 

In our litigious society, all health care professionals panicked.  An extremely restrictive interpretation of the HIPPA law was taken.  As a natural consequence, the hyper-protective process was set into place regarding any health information because no one wanted to be the first person or agency or hospital to be sued.  The courts had not yet interpreted this law; and therefore the medical and health care profession wanted to be sure that they were covered.

Sometimes people ask us why The Special Gathering does advocacy.  We are a ministry within the mentally challenged community.  We do classic ministry, evangelism and discipleship.  Why do we extend ourselves in this direction?  It is because much of the lives of our members is involved with the State.   After a state or federal law is passed then it must be interpreted by the courts.  There are many unintended consequences to each law. 

Even after a law is set into motion, the state agencies must write rules which will implement this law.  Again, an array of unintended consequences.  The state and federal politicians, many of whom are lawyers, have a hard time remembering and understanding what a simple law may become.  How is it possible for a family member or a person who is developmentally delayed to understand and to remember the myriad of rules and regulation which control her lives.

This information was passed on to me through our blogsite from the APD State office.  It contains the rules that will be used by APD to help keep costs down for people who are living in their own apartments.  After almost an hour of trying to cut and paste this document onto the blogsite, I give up.  Here is the address that you can use to access it. 


Whether you are a parent or professional, I believe this is an important document for you to read and keep.

We’ve all seen the ways that HIPPA has changed our lives.  What are some of the unintended consequences to actions taken in your life?  What about your members?  What actions changed your members’ lives and made them better people?


Week of March 24, 2008

  This week was dominated with the House and Senate budget committees finalizing their separate initial budget recommendations and proposals including budget reductions for 2008 – 2009.  Historic reductions were proposed for all agencies comprising the health and human services budget including the Agency for Health Care Administration, The Agency for Persons with Disabilities, Elder Affairs, Department of Children and Families, Department of Health and Veterans Administration. 

Within the Agency for Health Care Administration, the Medicaid program was substantially reduced including critical services for families and their children.  Among the many Medicaid programs reduced or eliminated, the House proposal released today will prohibit adult dental, optometric services, podiatric services, visual services, and hospice services  from being provided to the general Medicaid population for a two year period.  Substantial reductions were also taken in hospital and nursing home services among many others. 

Both budget proposals provide for varying reductions for the Agency For Persons with Disabilities : 


1. 5% provider Rate Reduction for all providers – total savings of $43,544,549 

2.  A $150,000 cap for Tier One clients – total savings $5,634,451 

3.    An increase of $3,135,802 in additional funding to complete all      needs assessments of consumers in 2008-2009 

4.      A proposed reduction of the Gulf Coast Center by 60 beds during 2008-09 leaving 60 additional consumers to move the following year.

5.      Reduce contracts by $1,691,039 (Discussion of re-bidding PSA contracts)   


1.     3% Rate Reduction for all providers – total savings $23,397,023

2.     Additional funding to restore waiver services on a one time basis and address the APD deficit – total increase $54,515,896

3.     Move due process hearings back to DCF

4.     Freeze cost plans at actual expenditures for the previous fiscal year 

The House and Senate will continue to refine their separate budgets throughout the coming two weeks.  A conference committee will eventually be appointed to work out any differences between the two bills prior to the completion of the Appropriations process and sending a final bill to Governor Crist. 

Additional legislation will be filed this week by the Senate which will modify the consumer cost “Tiers” which were established during the 2007-2008 Legislative Session.  We do not know at this time what will be included within these changes, but will provide that information and continue to monitor the legislation when it is made available. 

In addition to budget proposals, House Bill 333, by Rep Nehr was heard and passed by the Healthcare Council.  This bill will require the APD to prepare plans for review and comment if there is an announced intent to close or reduce census by 20 percent or more at either Tacachale or Sunland Developmental Disabilities Institution.  The bill now moves to the Policy and Budget Council for further consideration. 

We continue to meet with members of the House and Senate, and meet with the other “stakeholders” to coordinate efforts.  We maintain our mission to hold APD consumers harmless from additional reductions, and specifically advocate for support coordination within all discussions. An update of all legislation currently being tracked will be forwarded for this week when it is completed. 

I want to thank Janice Phillips for her personal assistance, and the FASC membership and Board of Directors for continued support from throughout the state.  We will continue to keep you informed as developments occur.