Medicaid-Financed Institutional Services: Characteristics of Nursing Home and ICF/IID Residents and Their Patterns of Care. A. Characteristics of Enrollees Using Intermediate Care Facility for People with Intellectual Disabilities Services

08/01/2013

1. How Many Enrollees Had New Spells of ICF/IID Care?

Few Medicaid enrollees used ICF/IID services. Of the nearly 12 million enrollees who were either elderly or eligible on the basis of disability between July 1, 2006, and December 31, 2007, only 93,761 had been in an ICF/IID, and only 9 percent (8,430) of those individuals -- representing less than one-tenth of 1 percent of all elderly or disabled enrollees -- had new spells of care. Thus, turnover in ICFs/IID was significantly lower than the turnover rate reported for enrollees in nursing homes (Chapter II). The number of enrollees residing in ICFs/IID was also relatively low compared to the number of enrollees with ID/DD who received HCBS waiver services in the community: in 2006, approximately 410,000 individuals were enrolled in waivers for individuals with ID/DD (MR/DD waivers) in the states analyzed here (Ng and Harrington 2009).

Differences across states in the number of spells or new spells were likely due in part to different state policies with respect to ICFs/IID. For example, Oregon and Vermont, which have been leaders in promoting community-based care for the ID/DD population, each had only a single ICF/IID in 2007 and correspondingly low numbers of ICF/IID spells (zero, in the case of Oregon).22 As mentioned above with respect to nursing home users, a disproportionate number of new ICF/IID spells were concentrated in a handful of large states, with California, Texas, New York, and Illinois together accounting for 45 percent of all new spells. Although the percentage of ICF/IID spells that were new was substantially higher in some states--including Alaska, Montana, South Dakota, Rhode Island, and Colorado--the actual numbers of new spells in these states were low, together accounting for only one percent of all new spells.23

TABLE III.1. Medicaid FFS ICF/IID Use Among Aged or Disabled Enrollees Eligible for Full Medicaid Benefits Any Time Between July 2006 and December 2007
    Total Number of Aged  
and Disabled Enrollees
  Number of Enrollees  
with ICF/IDD Spells
Number of Enrollees
  with New ICF/IID Spells  
Percentage of Enrollees
  with New ICF/IID Spells  
  Percentage of ICF/IID Enrollees  
with New ICF/IID Spells
All States 11,922,095 93,761 8,430 0.1 9.0
Alabama 215,562 253 32 0.0 12.6
Alaska 22,542 b b b b
Arkansas 147,070 1,780 283 0.2 15.9
California 1,848,937 8,864 1,123 0.1 12.7
Colorado 115,524 150 30 0.0 20.0
Connecticut 113,746 1,261 115 0.1 9.1
Delaware 24,219 147 b b b
District of Columbia   43,901 695 89 0.2 12.8
Florida 661,152 3,060 135 0.0 4.4
Georgiaa 315,975 1,190 165 0.1 13.9
Hawaii 44,956 84 b b b
Idaho 44,065 617 93 0.2 15.1
Illinois 467,613 9,477 651 0.1 6.9
Iowa 101,732 2,332 167 0.2 7.2
Kansas 85,305 644 37 0.0 5.7
Kentucky 249,333 717 71 0.0 9.9
Louisiana 239,281 5,584 497 0.2 8.9
Maryland 168,074 342 19 0.0 5.6
Massachusetts 379,285 1,031 54 0.0 5.2
Michigan 413,303 143 20 0.0 14.0
Mississippi 185,700 2,921 336 0.2 11.5
Missouri 266,561 1,006 63 0.0 6.3
Montana 26,767 66 19 0.1 28.8
Nebraska 55,381 632 76 0.1 12.0
Nevada 45,739 144 22 0.0 15.3
New Jersey 288,719 3,074 177 0.1 5.8
New Mexico 77,024 274 34 0.0 12.4
New York 1,097,394 8,548 756 0.1 8.8
North Carolina 426,342 4,204 213 0.0 5.1
North Dakota 17,766 582 49 0.3 8.4
Ohio 471,689 7,793 617 0.1 7.9
Oklahoma 152,507 1,845 208 0.1 11.3
Oregon 107,585 0 0 0.0 0.0
Pennsylvania 685,973 4,077 193 0.0 4.7
Rhode Islanda 59,865 46 b b b
South Carolina 216,208 1,735 144 0.1 8.3
South Dakota 23,255 201 46 0.2 22.9
Tennesseea 391,227 1,280 36 0.0 2.8
Texas 803,650 12,696 1,225 0.2 9.6
Vermont 29,604 b b b b
Virginia 216,853 1,917 193 0.1 10.1
Washington 232,549 59 b b b
West Virginia 122,980 569 92 0.1 16.2
Wisconsin 207,083 1,572 307 0.1 19.5
Wyoming 12,099 98 11 0.1 11.2
SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTES: New spells are spells beginning on or after July 1, 2006.
  1. Data for Georgia, Rhode Island, and Tennessee were included in the analysis even though total institutional care expenditures as reported by the MAX data and CMS Form 64 differed substantially (a variance across data sources of at least 33% in 2007), as there were no known data anomalies for these states believed to invalidate the MAX-based statistics.
  2. Cell sizes of less than 11 are not displayed.

Although much emphasis has been placed on re-balancing services for the ID/DD population toward community settings in the wake of the Olmstead decision, concerns have been raised about the lack of institutional capacity in some states for individuals with complex needs (Western Interstate Commission for Higher Education 2009). For example, because no ICF/IID was located in Alaska during the study period, it placed its four enrollees requiring institutional services in three Idaho facilities.

2. Who Used ICF/IID Care?

The majority of enrollees with new ICF/IID spells were male and under 65 years old, with a substantial number having multiple spells of care during the study period. Unlike nursing homes, whose residents are more likely to be female and elderly, 60 percent of the 8,430 enrollees with ICF/IID spells were male, and 38 percent were between 21 and 44 years old (Table III.2). Significant percentages of enrollees residing in ICFs/IID were younger than 21 (29 percent) or between 45 and 64 years old (27 percent).

TABLE III.2. Characteristics of Aged or Disabled Enrollees with New Medicaid-Financed ICF/IID Spells Between July 2006 and December 2007
Characteristic Enrollees with One or
  More New ICF/IID Spells  
  Enrollees with Both New  
Nursing Home and New
ICF/IID Spells
Number of Enrollees with New Spells in All States 8,430 994
   Percentage female 40.1 47.4
   Percentage non-Hispanic White 72.1 80.7
Age (Percentage of Subgroup)
   Under age 21 29.0 4.4
   21-44 years 38.4 29.5
   45-64 years 26.5 49.0
   65-74 years 3.8 10.0
   75-84 years 1.5 5.4
   85 years and older 0.4 1.7
Percentage with Multiple New Spells 14.6 100.0
Percentage with Spells in Both Nursing Homes and ICFs/IID   11.8 100.0
SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTE: New spells are spells beginning on or after July 1, 2006.

Of all enrollees with new spells of ICF/IID care, 15 percent had more than one new spell within the 18-month period between July 2006 and December 2007, and 12 percent had spells in both ICFs/IID and nursing homes (discussed in greater detail below). Older women were much more prevalent among those who used both ICFs/IID and nursing homes: slightly less than half of all enrollees who received both types of institutional care were female, and 17 percent were over 65 years old, compared with only 6 percent for enrollees with only ICF/IID spells. It is possible that some ICF/IID residents were moved to nursing homes as they grew older and required more complex and continual medical care, but the vast majority of enrollees with stays in both types of institution (83 percent) were younger than 65.

TABLE III.3. MAS in First Month of First New Medicaid-Financed ICF/IID Spell Among Aged or Disabled Enrollees Eligible for Full Medicaid Benefits Any Time Between July 2006 and December 2007
States
  (by largest MAS group)  
  Total Number of Enrollees  
with new ICF/IID Spells
Percentage in MAS Group at Start of Spell
  "Other"   Cash
  Assistance-  
Related
  Medically  
Needy
  Poverty-  
Related
Section 1115
  Demonstration  
Waiver
Cash Assistance
   Alaskac e e e e e e
   Rhode Islandabc e e e e e e
   Georgiaabc 165 21.8 78.2 0.0 0.0 0.0
   New Mexicoc 34 e e e e e
   Idahoc 93 e 71.0 e e e
   Texasc 1,225 33.1 66.6 e e e
   South Dakotac 46 e 63.0 e e e
   Delawarec e e e e e e
   Floridabc 135 35.6 61.5 e e e
   Mississippic 336 38.4 61.3 e e e
   North Carolinab 213 e 60.1 e 33.3 e
   Michiganbc 20 e e e e e
   District of Columbiab   89 e e e e e
   Tennesseeabc 36 e e e e e
   Montanab 19 e e e e e
   Kansasbc 37 43.2 56.8 0.0 0.0 0.0
   Wisconsinbc 307 39.7 56.7 e e e
   Coloradoc 30 43.3 56.7 0.0 0.0 0.0
   South Carolinac 144 27.1 56.3 0.0 16.7 0.0
   Louisianabc 497 44.1 55.3 e e e
   Arkansasbc 283 46.3 52.7 e e e
   Californiab 1,123 4.5 51.4 41.7 2.4 0.0
   North Dakotabd 49 0.0 51.0 49.0 0.0 0.0
   Hawaiibd e e e e e e
All States 8,430 32.5 48.2 15.4 3.9 0.1
   Massachusettsb 54 e e e e e
"Other"
   Vermontbc e e e e e e
   Washingtonbc e e e e e e
   Wyomingc 11 e e e e e
   Oklahomacd 208 81.3 13.5 0.0 5.3 0.0
   Connecticutbd 115 73.0 24.3 2.6 0.0 0.0
   Ohiod 617 69.5 25.0 0.0 5.5 0.0
   Missourid 63 66.7 33.3 0.0 0.0 0.0
   New Jerseybc 177 66.7 30.5 e e e
   Iowabc 167 60.5 39.5 0.0 0.0 0.0
   Virginiabcd 193 57.0 38.9 e e e
   Nevadac 22 e e e e e
   West Virginiabc 92 53.3 43.5 e e e
   Pennsylvaniabc 193 52.3 40.4 e e e
   Kentuckybc 71 52.1 43.7 e e e
   Alabamac 32 50.0 46.9 e e e
Medically Needy
   Nebraskab 76 e e 57.9 e e
   New Yorkb 756 e e 55.7 e e
   Marylandbc 19 e e e e e
   Illinoisbd 651 25.7 22.4 40.4 11.5 0.0
SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTE: New spells are spells beginning on or after July 1, 2006. MAX data reported no new ICF/IID spells in Oregon. Methods used to determine which states utilized the 300% rule or had a medically needy program in 2007 are described in Appendix B.
  1. Data for Georgia, Rhode Island, and Tennessee were included in the analysis even though total institutional care expenditures as reported by the MAX data and CMS Form 64 differed substantially (a variance across data sources of at least 33% in 2007), as there were no known data anomalies for these states believed to invalidate the MAX-based statistics.
  2. State had a medically needy program in 2007.
  3. State utilized the 300% rule in 2007.
  4. Section 209(b) state. Because Section 209(b) states are required to allow persons receiving SSI to deduct incurred medical expenses from income to determine financial eligibility, some people in 209(b) states may be coded as medically needy even if the state had no medically needy program.
  5. Cell sizes of less than 11 are not displayed.

3. How Did Enrollees Residing in ICFs/IID Become Eligible for Medicaid?

More enrollees using ICF/IID services qualified for Medicaid benefits through cash assistance-related criteria than through any other pathway, with the vast majority already enrolled in Medicaid prior to admission. Across all 45 states, nearly half of all enrollees in ICFs/IID qualified for full-benefits via the cash assistance pathway in 2007, followed by "other" criteria (33 percent) and medically needy programs (15 percent) (Table III.3).24 In roughly half of states analyzed (23 out of 45), the majority of ICF/IID residents with new spells qualified for Medicaid at the start of their spell due to their low-incomes -- that is, they qualified under cash assistance-related criteria. Moreover, in all states except Illinois cash assistance-related criteria represented either the most common or second most common pathway to Medicaid eligibility. Finally, cash assistance was the most common pathway to eligibility in the two states with the largest number of new spells: California and Texas. "Other" criteria were the most common pathway to eligibility in 15 states -- one-third of which are 209(b) states -- while medically needy programs were the most common pathway in four states. As with enrollees in nursing homes, poverty-related expansions were a common pathway to eligibility in Hawaii, Massachusetts, and North Carolina.

In contrast to enrollees in nursing homes, most enrollees living in an ICF/IID were enrolled in Medicaid prior to their first spell of institutional care, with only 11 percent not enrolled two months prior to admission (Table III.4). Among those qualifying for benefits two months prior to their ICF/IID stay, most qualified either via cash assistance (48 percent) or "other" (24 percent). Cash assistance was either the most common or second most common pathway to eligibility in all states except Illinois. Thus, recipients of Medicaid-financed ICF/IID services generally had low-incomes and were not spending down available assets as many nursing home residents do. As with enrollees in nursing homes, retroactive eligibility for Medicaid benefits at the time of admission to the ICF/IID likely accounts for some of the observed enrollment in Medicaid two months prior to admission.

TABLE III.4. MAS in the Two Months Preceding the First New Medicaid-Financed ICF/IID Spells of Aged or Disabled Enrollees Between July 2006 and December 2007
States
(by largest MAS group)
  Total Number of Enrollees  
with new Nursing Home Spells
Percentage in MAS Group at Start of Spell
Not
  Enrolled 
  "Other"   Cash
  Assistance-  
Related
  Medically  
Needy
  Poverty-  
Related
Section 1115
  Demonstration  
Waiver
Cash Assistance
   Alaskac e e e e e e e
   Rhode Islandabc e e e e e e e
   Vermontbc e e e e e e e
   Georgiaabc 165 e 15.8 75.2 e e e
   South Carolinac 144 e 17.4 67.4 e e e
   Michiganbc 20 e e e e e e
   Tennesseeabc 36 e e e e e e
   Marylandbc 19 e e e e e e
   Montanab 19 e e e e e e
   South Dakotac 46 e e 63.0 e e e
   District of Columbiab   89 e e 62.9 e e e
   Mississippic 336 e 21.4 61.9 e e e
   New Mexicoc 34 e e 61.8 e e e
   Texasc 1,225 16.5 16.0 60.7 e e e
   North Carolinab 213 e 0.0 60.1 e 25.4 e
   Wisconsinbc 307 e 36.5 57.3 e e e
   Louisianabc 497 e 19.9 56.5 e e e
   Idahoc 93 20.4 e 55.9 e e e
   Floridabc 135 e 25.2 53.3 e e e
   Californiab 1,123 6.0 3.9 53.3 33.0 3.5 0.0
   Alabamac 32 e e 53.1 e e e
   North Dakotabd 49 e e 53.1 e e e
   New Yorkb 756 e e 51.9 e e e
   Kansasbc 37 e e 51.4 e e e
   Delawarec e e e e e e e
   Hawaiibd e e e e e e e
   Arkansasbc 283 e e 48.8 e e e
   Pennsylvaniabc 193 e e 48.2 e e e
   Massachusettsb 54 e e 48.1 e e e
All States 8,430 10.9 23.8 47.8 10.8 5.7 0.1
   Coloradoc 30 e e 46.7 e e e
   Kentuckybc 71 e e 45.1 e e e
   West Virginiabc 92 e e 43.5 e e e
   Virginiabcd 193 e e 43.0 e e e
   Nevadac 22 e e e e e e
"Other"
   Oklahomacd 208 e 37.0 34.6 e e e
   New Jerseybc 177 e 62.1 18.1 e e e
   Ohiod 617 10.2 61.8 21.2 0.0 5.7 0.0
   Wyomingc e e e e e e e
   Alaskac 167 e 64.1 e 0.0 0.0 0.0
   Connecticutbd 115 e 61.7 e e e e
   Missourid 63 e 69.8 e e e e
   Washingtonbc e e e e e e e
Medically Needy
   Nebraskab 76 e e e 48.7 e e
   Illinoisbd 651 e 29.3 16.3 30.7 15.7 e
SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Alaska, Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTES: New spells are spells beginning on or after July 1, 2006. MAX data reported no new ICF/IID spells in Oregon. Methods used to determine which states utilized the 300% rule or had a medically needy program in 2007 are described in Appendix B.
  1. Data for Georgia, Rhode Island, and Tennessee were included in the analysis even though total institutional care expenditures as reported by the MAX data and CMS Form 64 differed substantially (a variance across data sources of at least 33% in 2007), as there were no known data anomalies for these states believed to invalidate the MAX-based statistics.
  2. State had a medically needy program in 2007.
  3. State utilized the 300% rule in 2007.
  4. Section 209(b) state. Because Section 209(b) states are required to allow persons receiving SSI to deduct incurred medical expenses from income to determine financial eligibility, some people in 209(b) states may be coded as medically needy even if the state had no medically needy program.
  5. Cell sizes of less than 11 are not displayed.

ICF/IID residents who were enrolled in Medicaid prior to admission generally continued to qualify for benefits according to the same eligibility criteria following admission, with 87-93 percent of those who qualified via the "other," cash assistance, and medically needy pathways remaining in the same MAS group (Table III.5). As with nursing homes, the percentage remaining in the poverty-related group (46 percent) was lower, with most of those enrollees qualifying for benefits under "other" criteria following admission. Among those residents who were not enrolled in Medicaid two months prior to admission, approximately half qualified for Medicaid via the "other" pathway, with the remainder qualifying via the cash assistance (29 percent) and medically needy (19 percent) pathways.

TABLE III.5. Transitions in MAS at the Start of First New Medicaid-Financed ICF/IID Spells Between July 2006 and December 2007
  MAS Group Two Months  
Before Start of Spell
  Number in MAS Group Two  
Months Before Start of Spell
Percentage in MAS Group at Start of Spell
  "Other"   Cash
  Assistance-  
Related
  Medically  
Needy
  Poverty-  
Related
Section 1115
  Demonstration  
Waiver
Not enrolled 915 49.2 29.0 18.5 a a
"Other" 2,006 87.4 8.5 2.2 a a
Cash assistance 4,028 7.8 87.0 4.5 a a
Medically needy 912 a 5.6 92.9 a a
Poverty-related 479 37.4 7.7 8.8 46.1 0.0
Section 1115 demonstration waiver   12 a a a a a
SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTES: New spells are spells beginning on or after July 1, 2006. MAX data reported no new ICF/IID spells in Oregon.
  1. Cell sizes of less than 11 are not displayed.

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