An Investigation of Interstate Variation in Medicaid Long-Term Care Use and Expenditures Across 40 States in 2006. Appendix A. Glossary of Terms

07/01/2013

This glossary summarizes the operational definitions of terms used in this report. For more general definitions of Medicaid terms, see Schneider et al. (2002).

Age: Age is defined as of December 31, 2006.

Adult (BOE Group): A BOE group that includes pregnant women and caretaker relatives in families with dependent children. (Adults who are eligible for Medicaid due to disability are coded as disabled.)

Aged (BOE Group): A BOE group that includes enrollees age 65 or older who qualify for Medicaid due to their age. Because some states code all people over 65 as aged, enrollees older than 65 but categorized in another BOE group in MAX were recoded as aged for this study.

Basis of Eligibility (BOE): Eligibility grouping that traditionally has been used by CMS to classify enrollees as children, adults, aged, or disabled.

Child (BOE Group): A BOE group that includes persons under age 18 or under age 21 in states electing to cover older children. (Children who are eligible for Medicaid due to disability are coded as disabled.)

Disabled (BOE Group): A BOE group that includes persons of any age (including children) who are unable to engage in substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months. Because disabled people over 65 are often but not always categorized as aged, all disabled people over 65 were recoded as aged in this study.

Fee-For-Service (FFS): A payment mechanism in which payment is made for each utilized service. FFS services exclude services provided under capitated arrangements.

Home and Community-Based Services (HCBS): 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.

Home Health: Services provided at a patient's place of residence (typically a patient's home), in compliance with a physician's written plan of care that is reviewed every 62 days. These include nursing services, as defined in the State Nurse Practice Act, home health aide services, physical therapy, occupational therapy or speech pathology, and audiology services that are provided by a HHA or a facility licensed by the state to provide these medical rehabilitation services.

Institutional Long-Term Care (ILTC): Nursing facility services, services provided in ICFs/IID, mental hospital services for people over age 65, and inpatient psychiatric facility services for individuals under age 21.

Intermediate Care Facility for People with Intellectual Disabilities (ICFs/IID): ICFs/IID are Medicaid-financed facilities for the care of individuals with ID/DD. These institutions are an optional Medicaid benefit that states may choose to offer; they are required to have four or more beds and offer treatment or rehabilitative services to people with ID/DD.

Managed Care: Payment mechanism used to manage health care, including services provided by health maintenance organizations (HMOs), PACE, prepaid health plans, and primary care case management plans. Services provided under managed care plans are not included in the measures summarized in this report.

Personal Care: Personal services, such as bathing and toileting, sometimes expanded to include light housekeeping furnished to an individual who is not an inpatient or a resident of a group home, assisted living facility, or long-term facility, such as a hospital, nursing facility, ICF/IID, or institution for mental disease. Personal care services are those that individuals typically would accomplish themselves if they did not have a disability.

Private Duty Nursing: Services, except those for mental health or substance abuse treatment, provided by registered nurses or licensed practical nurses under direction of a physician to recipients in their own homes, hospitals, or nursing facilities, as specified by the state.

Residential Care: Although room and board services provided in residential care facilities are not covered by Medicaid, other components of residential care -- for example, personal care, 24-hour services, and chore services -- can be covered. Residential care includes group, family, or individual home residential care; cluster residential care; and therapeutic residential care services, assisted living, supported living, and night supervision.

Program of All-Inclusive Care for the Elderly (PACE): A managed care plan that coordinates both acute and LTC for eligible enrollees (those 55 and older, living in a PACE area, and otherwise eligible for nursing home care). A capitated payment mechanism is used for PACE plan enrollees. As a result, service-specific information is not available for services provided under PACE or other managed plans.

Restricted-Benefit Enrollees: Enrollees who receive limited Medicaid coverage, including unqualified aliens eligible only for emergency benefits, Qualified Medicare Beneficiaries, and people eligible for only family planning services. Some enrollees may be eligible for a restricted set of services but are coded as full-benefit enrollees -- for example, those eligible for prescription drug coverage and Medicare cost sharing only.

Waiver: Services provided under Section 1915(c) of the Social Security Act that enable states to provide Medicaid-financed community-based LTC for people who otherwise would require Medicaid-covered hospital care, nursing facility care, or care in an ICF/IID. These programs can be designed to target individuals in specific age groups and with specific conditions, and the services can be restricted to certain areas of the state. (Other types of Medicaid waivers -- for example, 1115 waivers that cover population subgroups not generally covered under Medicaid, or those that fundamentally change service delivery -- are not discussed in this report.)

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