Although institutional services were historically the dominant type of services for people with IDD, they currently serve a much smaller proportion of the population. Only 13% of all individuals with IDD who used LTSS services in FY2013 resided in intermediate care facilities for individuals with intellectual disabilities (ICF/IDs) (Braddock et al., 2014). ICF/IDs are institutions that provide both medical care and long-term care services to individuals with IDD. Such facilities provide ongoing evaluation, planning, 24-hour supervision, coordination, and integration of health or rehabilitative services to help each resident function at his or her greatest ability. ICF/IDs (1) are primarily for the diagnosis, treatment, or rehabilitation for individuals with intellectual disabilities; and (2) provide, in protected residential settings, ongoing evaluation, planning, 24-hour supervision, coordination, and integration for health or rehabilitative services to help individuals function at their greatest ability (42 CFR 435.1009) . Medicaid spent $12.8 billion for ICF/IDs in FY2012 (Eiken et al., 2014a). About 95,500 Medicaid beneficiaries received services in ICF/ID in FY2010 (Eiken et al., 2014b). The number of individuals with IDD served in ICF/IDs has fallen substantially over time. Between 1993 and 2012 the number of people in public ICF/IDs decreased from 147,729 to 86,000 but total Medicaid ICF/ID expenditures increased from $9.2 billion to $12.3 billion. Overall ICF/ID expenditures increased 34% but the number of participants declined 42% during this time period (Larson et al., 2014).