Interstate Variation and Progress Toward Balance in Use of and Expenditure for Long-Term Services and Supports in 2009. Appendix C. State Long-term Services and Supports Data Anomalies

03/18/2014

MAX data are derived from enrollment and claims data files that are submitted by states to CMS. Due to differences in state reporting systems and capabilities, MAX data contain some state-specific anomalous and possibly incomplete or incorrect data. Data anomalies that are most relevant to the analyses of MAX 2009 data that are presented in this report are listed in Table C.1. A detailed list of all MAX 2009 data anomalies is available from the CMS website at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/MAXGeneralInformation.html.

In addition to examining MAX 2009 data anomalies, we compared reported expenditures for LTSS, including Section 1915(c) waiver services, all HCBS, and also institutional LTSS (NF and ID/DD services), to expenditures for FY 2009 reported by states to CMS in the Form 64. We also compared Section 1915(c) waiver enrollment to enrollment counts in Form 372 data (as reported in KFF 2012). These sources provided additional benchmarks for assessing the magnitude of MAX data anomalies and context for our results.

Based on these analyses, we excluded 13 states from all analyses. Maine was excluded because complete 2009 data were unavailable. Arizona, Hawaii, Minnesota, New Mexico, Oregon, Pennsylvania, and Tennessee were excluded because they provide most services, or at least the majority of LTSS, to Medicaid enrollees who are aged or have disabilities via managed care arrangements and this analysis focused on services provided on a FFS basis. Massachusetts, Michigan, Montana, Rhode Island, and Wisconsin were excluded because we concluded from comparisons with Form 64 and assessments of MAX data anomalies that their HCBS data were potentially unreliable. The District of Columbia, Vermont, and Washington were excluded from analyses of populations with physical disabilities or ID/DD because waiver data used to identify these populations was not reported in MAX 2009 and individuals with ID/DD could not be distinguished from other enrollees in these states.


TABLE C.1. MAX 2009 State LTSS Data Anomalies

State   Excluded From Study   Anomalies
All States --- Expenditures reported as service tracking claims are not included in MAX as they cannot be attributed to specific enrollees.
Alabama --- No notes.
Alaska --- Alaska had a state-operated Pioneers Home System, not included in Medicaid that provided services to many people who might otherwise be in a NF. NF expenditures in MAX ($81 million) were about 31% lower than in Form 64 ($119 million). Average Medicaid expenditures in MAX for NF services, however, were consistent with previous years.
Arizona X Over half of enrollees who are aged or had disabilities were enrolled in managed care in 2009, including about 55,000 enrollees in managed LTSS, and more than half of the remaining Medicaid enrollees are in the Indian Health Service, so FFS distributions are unusual. HCBS expenditures in MAX (about $420,000) were about 95% lower than in Form 64 ($9.0 million). As a result, Arizona is excluded from the analyses presented in this report.
Arkansas --- Arkansas reported a small PACE program with fewer than 50 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data.
California --- California reported a PACE program with about 2,700 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data.
Colorado --- Colorado reported a PACE program with about 1,900 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data.
Connecticut --- Section 1915(c) waiver expenditures were about 36% lower in MAX ($808 million) than in Form 64 ($1.3 million) due to lower than expected claims for individuals in ID/DD waivers.
Delaware --- No notes.
District of Columbia   Excluded from analyses of individuals with physical disabilities and ID/DD only There were about 40% more Section 1915(c) waiver enrollees in MAX (4,300) than in Form 372 data (3,100). Reported waiver expenditures in MAX, however, were within 5% of expenditures in Form 64. District of Columbia did not report any individuals with ID/DD who used LTSS and was excluded from analyses that focused on the individuals with physical disabilities and those with ID/DD.
Florida --- Florida reported a PACE program with about 300 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data.
Georgia --- No notes.
Hawaii X Almost all Medicaid enrollees who were aged or had disabilities were enrolled in managed care in 2009, so FFS distributions are unusual. HCBS expenditures in MAX ($25,000) were more than 95% lower than expenditures in Form 64 ($139 million). In addition, ILTC expenditures were about 99% lower in MAX ($250,000) than in Form 64 ($115 million). As a result, Hawaii is excluded from the analyses presented in this report.
Idaho --- No notes.
Illinois --- HCBS expenditures in MAX ($1.4 million) were about 52% higher than expenditures in CMS-54 data ($917 million). There are no indications, however, that HCBS information in MAX should be considered unreliable for Illinois.
Indiana --- No notes.
Iowa --- Iowa reported a PACE program with fewer than 100 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data.
Kansas --- Kansas reported a PACE program with about 300 enrollees in MAX 2009. Services provided through this program are not reported in MAX FFS data.
Kentucky --- There were about 37% more Section 1915(c) waiver enrollees reported in MAX (18,000) than in Form 372 data (13,000). Reported expenditures for these waivers in MAX ($341 million), however, were within 1% of reported expenditures in Form 64 ($344 million).
Louisiana --- Louisiana reported a PACE program with about 200 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data.
Maine X Maine did not submit complete and reliable inpatient, LTSS, or other claims in 2009. As a result, Maine is excluded from the analyses presented in this report.
Maryland --- Section 1915(c) waiver expenditures in MAX ($460 million) were about 35% lower than in Form 64 ($711 million). Lower expenditures in MAX appear to be caused by low levels of reported claims for children in autism waivers as well as for enrollees in waivers for individuals with physical disabilities. Maryland also reported a PACE plan with about 200 enrollees in MAX 2009.
Massachusetts X Massachusetts enrolled about 14,000 aged Medicaid enrollees in PACE and Senior Care Options plans in 2009, the latter being similar to PACE plans. Expenditures for services provided through these plans cannot be identified in MAX. Estimates of HCBS expenditures in MAX ($1.1 million) were about one-third lower than in Form 64 data ($1.7 million). Also, Section 1915(c) waiver enrollment cannot be identified in MAX 2009. As a result, Massachusetts is excluded from the analyses presented in this report.
Michigan X HCBS expenditures in MAX ($295 million) were about 65% lower than expenditures in Form 64 ($838 million). Estimated Section 1915(c) enrollment in MAX (11,500 enrollees) was about 40% lower than in Form 372 data (19,600 enrollees). MAX estimates may be lower in part due to enrollment in Section 1915(b)/(c) waivers in the state that provide HCBS through managed care arrangements. As a result, Michigan is excluded from the analyses presented in this report.
Minnesota X In 2009, Minnesota enrolled more than half of aged enrollees and about 15% of enrollees with disabilities in managed care plans, which included coverage for HCBS and 180 days of NF care. LTSS provided through these plans cannot be identified in MAX. Also, institutional LTSS expenditures were about 68% lower in MAX ($326 million) than in Form 64 ($1.0 billion). As a result, Minnesota is excluded from the analyses presented in this report.
Mississippi --- No notes.
Missouri --- No notes.
Montana X HCBS expenditures in MAX ($76 million) were about half the amount reported in Form 64 ($167 million). This discrepancy was partly caused by problems with linkages of claims and eligibility data in MAX 2009, which resulted in claims not always being appropriately linked to the enrollee who received the service. As a result, Montana is excluded from the analyses presented in this report.
Nebraska --- No notes.
Nevada --- No notes.
New Hampshire --- No notes.
New Jersey --- New Jersey reported a PACE program with about 130 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data.
New Mexico X In 2009, New Mexico moved all enrollees who used LTSS and all dual-eligibles into managed care, covering about 42,000 aged and Medicaid enrollees with disabilities in managed LTSS and PACE plans. Services provided through these plans are not included in MAX FFS data. HCBS expenditures in MAX ($213 million) were about 49% lower than in Form 64 ($420 million). Expenditures for institutional LTSS were about 50% lower in MAX ($40 million) than in Form 64 data ($84 million). As a result, New Mexico is excluded from the analyses presented in the report.
New York --- New York covered about 32,000 aged and Medicaid enrollees with disabilities in managed LTSS and PACE plans in 2009. Services provided through these plans are not included in MAX FFS data. HCBS expenditures, however, compare well with Form 64.
North Carolina --- North Carolina reported a PACE program with fewer than 100 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data.
North Dakota --- North Dakota reported a PACE program with fewer than 50 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data.
Ohio --- Ohio had a PACE program in 2009 that was not reported in MAX data.
Oklahoma --- North Dakota reported a PACE program with about 50 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data.
Oregon X Over half of enrollees who were aged or had disabilities were enrolled in managed care plans in 2009, including about 850 enrollees in PACE plans. HCBS expenditures in MAX ($197 million) were about 79% lower than in Form 64 ($959 million). Also, institutional LTSS expenditures in MAX ($226 million) were about 35% lower than in Form 64 ($349 million). As a result, Oregon is excluded from the analyses presented in this report.
Pennsylvania X About half (55%) of enrollees with disabilities were covered by managed care plans in 2009, including about 2,600 enrollees in PACE and managed LTSS plans. Services provided through managed care plans are not included in MAX FFS data. HCBS expenditures in MAX ($1.2 billion) were about 45% lower than in Form 64 ($2.2 billion). As a result, Pennsylvania is excluded from the analyses presented in this report.
Rhode Island X In July 2009, Rhode Island moved all Section 1915(c) waiver coverage to a Section 1115 waiver program and the enrollees in HCBS programs were no longer identifiable in MAX data. HCBS expenditures in MAX ($78 million) were about 71% lower than in Form 64 ($266 million). Also, institutional LTSS expenditures in MAX ($505 million) were about 65% higher than expenditures in Form 64 ($305 million). As a result, Rhode Island is excluded from the analyses presented in this report.
South Carolina --- South Carolina reported a PACE program with about 450 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data.
South Dakota --- No notes.
Tennessee X By 2009, Tennessee had moved almost all Medicaid enrollees to managed care plans -- with more than 80% of enrollees who were aged or had disabilities in these plans. HCBS expenditures in MAX ($123 million) were about 82% lower than in Form 64 ($674 million). Also, Section 1915(c) waiver enrollment was about 41% higher in MAX (14,900 enrollees) than in Form 372 data (10,500 enrollees). Finally, institutional LTSS expenditures were about 99% lower in MAX ($11.5 million) than in Form 64 data ($1.2 billion). As a result, Tennessee is excluded from the analyses presented in this report.
Texas --- Texas enrolled about one-third of Medicaid enrollees who were aged or had disabilities in managed care plans, including about 1,000 enrollees in PACE plans. Services provided through managed care plans are not included in MAX FFS data. Also, Texas did not report enrollment in two of its Section 1915(c) waivers in MAX in 2009. Reported expenditures for HCBS and ILTC in MAX, however, were comparable to Form 64 data.
Utah --- No notes.
Vermont Excluded from analyses of individuals with physical disabilities and ID/DD only Section 1915(c) waiver services were covered under Vermont's Section 1115 Global Commitment to Health waiver. The Global waiver puts most enrollees into a public managed care organization, but most services are reported as FFS in MAX. HCBS expenditures in MAX ($197 million) were about 250% higher than in Form 64 ($57 million). This difference may be the result of Vermont's coverage through an 1115 waiver and not an indication of the unreliability of MAX data. Individuals with ID/DD cannot be distinguished from enrollees with physical disabilities due to the way that Vermont provides HCBS.
Virginia --- Virginia reported a PACE program with about 500 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data.
Washington Excluded from analyses of individuals with physical disabilities and ID/DD only Washington did not report Section 1915(c) waiver enrollment in 2009, so people with physical disabilities and those with ID/DD could not be differentiated. Washington reported a PACE program with about 400 enrollees in MAX 2009. Services provided through this program are not included in MAX FFS data. Expenditures for institutional LTSS were about 36% lower in MAX ($477 million) than in Form 64 ($739 million). This was primarily caused by very low expenditures for ICFs/IID in MAX 2009.
West Virginia --- No notes.
Wisconsin X Lags in the submission of claims data for MAX 2009 resulted in missing Section 1915(c) waiver claims. Wisconsin had a PACE program in 2009 that was not reported in MAX data. HCBS expenditures were about 66% lower in MAX ($300 million) than in Form 64 ($873 million). Also, MAX (19,900 enrollees) includes about 65% fewer Section 1915(c) enrollees than Form 372 data (57,600 enrollees). Finally, institutional LTSS expenditures in MAX ($947 million) were about 32% lower than in Form 64 ($1.4 billion). As a result, Wisconsin is excluded from the analyses presented in this report.
Wyoming --- No notes.

 

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