The most commonly used indicators of LTSS system balance -- the percentage of LTSS spending allocated to HCBS and the proportion of LTSS users receiving HCBS -- have relied on two readily available and annually updated sources of state-level data on Medicaid expenditures and HCBS use. These include aggregate spending data by service type reported by states in CMS Form 64 (Eiken et al. 2011), and counts of waiver enrollees reported in CMS Form 372 combined with state survey-based counts of personal care and home health users, as summarized each year by the Kaiser Commission on Medicaid and the Uninsured and the University of California, San Francisco (KFF 2012). Although these data convey important information on system performance, they cannot be used to conduct subgroup analyses (except for some waiver populations). This limits the ability to measure the extent to which HCBS have reached all people who need them. For this reason, researchers and policymakers also use person-level administrative data in the CMS Medicaid Analytic eXtract (MAX) system to explore who is being served by Medicaid LTSS and to better understand system transformation.6 These projects include efforts to measure HCBS and institutional use and spending for various groups eligible for the MFP demonstration (Brown et al. 2008; Irvin and Ballou2010; Lester et al. 2013) and the AARP efforts to develop a state LTSS system scorecard that includes some person-based measures of system performance (Reinhard et al. 2011). We use MAX data in this analysis so that we can examine overall system performance, as well as performance for subgroups of Medicaid enrollees.
6 This study's predecessors summarized the strengths and limitations of MAX data for studying LTC (Wenzlow et al. 2008, 2011), finding that, although the MAX data were incomplete for some states, and service-specific information on HCBS was not reliable in all states, MAX provides useful information on which populations are receiving HCBS and how their use of HCBS compares to use of institutional care.