For the most part, we followed the methods used in our previous report, and originally developed in Wenzlowet al. (2008), to construct demographic profiles, HCBS and institutional care use, and expenditures using MAX 2009 for this study.
As described in Chapter I, we measure HCBS by use of Section 1915(c) waiver services or one of five state plan services -- personal care, residential care, home health, adult day care, and private duty nursing. HCBS are challenging to identify because they may include a variety of services -- for example, transportation or targeted case management -- that also may be used for reasons unrelated to LTSS. For this reason, we exclude such services from our definition of HCBS unless they were provided under waivers. Moreover, our analysis of MAX data suggested that, in many states, a large portion of hospice care is provided to people leaving nursing homes for short periods prior to death. Also, in many cases, this care is provided in hospices or nursing homes rather than the home. Because our aim is to understand the degree to which states support HCBS as an alternative to institutional care, we excluded state plan hospice from our operational definition of HCBS.
We identified Medicaid institutional LTSS solely by using service type information in MAX. The four institutional LTSS types of service include NF services, services provided in ICFs/IID, mental hospital services for people age 65 and older, and inpatient psychiatric facility services for people under age 21. Thus, we are not including people who are institutionalized and receiving LTSS in inpatient hospitals or other facilities.