We used MAX 2009 Person Summary (PS) files to develop measures of LTSS system performance. MAX PS files contain demographic and enrollment information for each Medicaid enrollee, as well as information on total Medicaid expenditures for services used during the calendar year, by service type. They also contain information on users of and spending on Section 1915(c) waiver services -- an important vehicle that most states use to provide HCBS to select populations.
We defined HCBS to include services covered under Section 1915(c) waivers and personal care, residential care, home health care, adult day care, and private duty nursing services that are mandatory or provided at state option outside of waiver programs. Institutional care includes nursing home care, ICF/IID care, inpatient psychiatric services for people under age 21, and psychiatric hospital services for those 65 and older.8 The MAX PS files cannot be used to differentiate between people using institutional care for long periods and those using Medicaid institutional care for acute events. This study's operational definition of ILTC thus includes all care received in the selected institutions, whether or not a person is using them for LTSS.9
Analyses were limited to Medicaid enrollees eligible on the basis of disability or age and who were eligible for full Medicaid benefits in 2009.10 We excluded enrollees in the Program of All-Inclusive Care for the Elderly (PACE) and other managed care plans because information on their use of services (HCBS or institutional care) is missing or unreliable in MAX in many states. We also reviewed MAX 2009 data documentation to identify data quality concerns related to LTSS use in each state. Based on these assessments, we excluded from the analysis 13 states with MAX fee-for-service (FFS) data that are potentially unrepresentative or unreliable due to high levels of managed care penetration among the aged and disabled population or due to data quality concerns. The excluded states are Arizona, Hawaii, Maine, Massachusetts, Michigan, Minnesota, Montana, New Mexico, Oregon, Pennsylvania, Rhode Island, Tennessee, and Wisconsin. Finally, we could not differentiate enrollees with physical disabilities from those with ID/DD in the District of Columbia, Vermont, and Washington, and excluded these states from the relevant subgroup analyses. A more detailed discussion of the MAX data, analyzed measures, and methods used is in Appendix B. Appendix C lists state-specific MAX data anomalies for 2009.
The analysis of state constraints and policies related to LTSS provision relied on a wide range of publicly available data sources. When available, we used data from 2009 to capture policies in place and state characteristics at the time that services were being used.
8 An individual can receive both HCBS and institutional care during the year.
9 The PS files do not contain information on the timing or length of institutional stays. MAX claims, which were not used for this study, are needed for such analyses.
10 The population of enrollees eligible for full Medicaid benefits excludes the following enrollees with restricted Medicaid benefits: Medicare-Medicaid enrollees who are eligible only for Medicare cost-sharing, aliens eligible only for emergency services, individuals eligible only for family-planning services, and individuals eligible only for premium assistance support toward the purchase of private health insurance.