Medicaid-Financed Institutional Services: Characteristics of Nursing Home and ICF/IID Residents and Their Patterns of Care. A. Characteristics of Enrollees Using Nursing Home Services

08/01/2013

1. How Many Enrollees Had New Spells of Nursing Home Care?

Of the nearly 12 million Medicaid enrollees living in selected study states who were elderly or eligible on the basis of disability, 694,111 enrollees, or about 6 percent, had at least one new nursing home spell (Table II.1).4 In some states, enrollees with new spells constituted a somewhat higher percentage, accounting for more than one in ten of all enrollees in Connecticut, Nebraska, North Dakota, and South Dakota who were either elderly or disabled.

Although enrollees with new spells represented only a small percentage of elderly or disabled Medicaid enrollees, they accounted for nearly half of the 1,556,712 enrollees who had a Medicaid-financed nursing home stay, demonstrating substantial turnover. Nearly half of all nursing home spells from the second half of 2006 through 2007 were new. The relatively high turnover in nursing home beds for Medicaid enrollees could have resulted from shorter stays due to hospitalization, death, or admissions for post-acute care. The percentage of new spells varied little across states, although new spells were especially common in Alaska (61 percent) and Oregon (57 percent), where stays tended to be shorter.5

TABLE II.1. Medicaid FFS Nursing Home Use Among Aged or Disabled Enrollees Eligible for Full Medicaid Benefits Any Time Between July 2006 and December 2007
    Total Number of  
Aged &
Disabled Enrollees
  Number of Enrollees  
with Nursing
Home Spells
  Number of Enrollees  
with New Nursing
Home Spells
  Percentage of Enrollees  
with New Nursing
Home Spells
  Percentage of Nursing  
Home Enrollees with
New Nursing
Home Spells
All States 11,922,095 1,556,712 694,111 5.8 44.6
Alabama 215,562 27,876 10,706 5.0 38.4
Alaska 22,542 1,345 815 3.6 60.6
Arkansas 147,070 19,767 7,731 5.3 39.1
California 1,848,937 135,073 70,588 3.8 52.3
Colorado 115,524 16,764 7,407 6.4 44.2
Connecticut 113,746 33,206 14,254 12.5 42.9
Delaware 24,219 4,048 1,653 6.8 40.8
District of Columbia   43,901 3,854 1,461 3.3 37.9
Florida 661,152 81,875 36,996 5.6 45.2
Georgiaa 315,975 41,558 16,594 5.3 39.9
Hawaii 44,956 5,128 2,268 5.0 44.2
Idaho 44,065 5,269 2,576 5.8 48.9
Illinois 467,613 83,217 38,558 8.2 46.3
Iowa 101,732 20,989 8,416 8.3 40.1
Kansas 85,305 16,532 7,370 8.6 44.6
Kentucky 249,333 30,556 15,676 6.3 51.3
Louisiana 239,281 32,124 14,396 6.0 44.8
Maryland 168,074 26,063 10,880 6.5 41.7
Massachusetts 379,285 58,382 28,055 7.4 48.1
Michigan 413,303 49,741 22,790 5.5 45.8
Mississippi 185,700 24,115 10,682 5.8 44.3
Missouri 266,561 43,706 19,985 7.5 45.7
Montana 26,767 5,635 2,404 9.0 42.7
Nebraska 55,381 12,722 5,888 10.6 46.3
Nevada 45,739 5,220 2,606 5.7 49.9
New Jersey 288,719 47,434 20,008 6.9 42.2
New Mexico 77,024 6,879 2,936 3.8 42.7
New York 1,097,394 158,009 60,324 5.5 38.2
North Carolina 426,342 47,534 22,570 5.3 47.5
North Dakota 17,766 5,672 2,201 12.4 38.8
Ohio 471,689 94,063 44,485 9.4 47.3
Oklahoma 152,507 24,417 10,655 7.0 43.6
Oregon 107,585 11,863 6,725 6.3 56.7
Pennsylvania 685,973 89,919 37,591 5.5 41.8
Rhode Islanda 59,865 11,436 4,360 7.3 38.1
South Carolina 216,208 18,471 8,101 3.7 43.9
South Dakota 23,255 6,413 2,647 11.4 41.3
Tennesseea 391,227 36,642 16,543 4.2 45.1
Texas 803,650 106,010 45,736 5.7 43.1
Vermont 29,604 3,987 1,840 6.2 46.1
Virginia 216,853 29,441 13,260 6.1 45.0
Washington 232,549 22,494 11,483 4.9 51.0
West Virginia 122,980 12,258 5,259 4.3 42.9
Wisconsin 207,083 36,421 15,557 7.5 42.7
Wyoming 12,099 2,585 1,075 8.9 41.6
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.

Three states -- California, New York, and Texas -- accounted for more than 25 percent of all enrollees with new spells (175,000), while seven states (including Florida, Illinois, Ohio, and Pennsylvania) accounted for nearly half of all enrollees with new spells. Consequently, the characteristics of both residents and spells discussed in this chapter were heavily influenced by these states.

2. How Did Nursing Home Utilization Change Over Time?

By allowing more individuals who might have otherwise required institutionalization to remain in the community, the expansion of HCBS programs might have contributed to changes in: (1) the number of elderly and persons with disabilities enrolled in Medicaid; and (2) the number and characteristics of enrollees living in nursing homes. Expansions of HCBS might encourage individuals who previously lacked access to community-based options to enroll in Medicaid, while also providing some institutionalized enrollees with the opportunity to transition back to their communities. As a result, both the number of enrollees who might become LTC users and the population and characteristics of enrollees living in nursing homes could change over time.

From 2001-2002 to 2006-2007, the number of Medicaid enrollees who were either elderly or disabled declined overall (by 3 percent) and in 32 of the 41 states for which reliable MAX data were available for both time periods (Table II.2).6 These results suggest that if increased access to HCBS led to greater Medicaid enrollment, other factors (such as rising incomes or changes in state Medicaid eligibility qualifications) had a much larger effect, resulting in the decline in enrollment. For example, the sharp decline in the number of elderly and persons with disabilities enrolled in Mississippi most likely reflected a policy change in 2005 that required face-to-face interviews in order to receive or renew benefits: from 2004 to 2006, the number of children and adults enrolled in Medicaid and the Children's Health Insurance Program fell by 62,000 (Lueck 2009).

There were slight declines in the use of nursing home care -- with the number of elderly or disabled enrollees who used Medicaid-financed nursing home services falling 4 percent and the percentage with new spells declining nearly 6 percent -- suggesting that in recent yearsnursing home beds have turned over more slowly. However, these modest overall changes masked substantial variation across states. A small number of states showed sharp increases in the number of enrollees with nursing home spells, including Alaska (a 35 percent increase), North Carolina (22 percent), and Rhode Island (18 percent). Similarly, the fraction of spells that were new declined in 27 of 42 states while showing substantial increases in Alaska (26 percent), Illinois (20 percent), and Kentucky (11 percent). This wide variation likely reflects a combination of influences, such as differences in the rates of expansion of HCBS programs, variation in the number of transitions from nursing homes to the community, different rates of change in the health of the Medicaid population, and differences in the extent to which nursing homes are used for post-acute care as opposed to LTC.

TABLE II.2. Percentage Changes in Medicaid FFS Nursing Home Use from 2001-2002 to 2006-2007
    Total Number of Aged  
& Disabled Enrollees
  Number of Enrollees with  
Nursing Home Spells
  Number of Enrollees with  
New Nursing Home Spells
  Percentage of Nursing Home  
Spells That Are New
All States -2.9 -3.5 -5.9 -2.4
Alabama -10.7 -5.0 -11.7 -7.0
Alaska +6.7 +34.6 +69.1 +25.6
Arkansas -12.6 -10.1 -9.5 +0.7
California +3.7 +1.8 -1.4 -3.1
Colorado -0.1 -5.8 -14.1 -8.8
Connecticut -9.6 -2.2 -1.4 +0.8
Delaware -4.2 +3.7 -6.2 -9.6
Florida -15.3 -12.4 -24.5 -13.8
Georgia -14.1 -9.6 -19.2 -10.6
Idaho +3.9 -10.5 -19.9 -10.4
Illinois +2.3 -8.0 +10.2 +19.7
Iowa -3.7 -8.6 -11.1 -2.8
Kansas -3.0 -10.5 -9.3 +1.3
Kentucky -11.9 +1.5 +12.8 +11.2
Louisiana -9.7 -10.5 -6.3 +4.8
Maryland -10.0 -0.3 -7.2 -7.0
Massachusetts   -1.3 -6.1 -5.6 +0.5
Mississippi -27.4 +9.9 +16.9 +6.3
Missouri -4.1 -1.3 -2.5 -1.2
Montana -16.4 -6.8 -11.6 -5.1
Nebraska -5.9 -4.5 +0.6 +5.3
Nevada -4.7 -4.1 -11.9 -8.2
New Jersey -5.9 -4.0 -10.3 -6.5
New Mexico +1.7 -11.2 -18.4 -8.1
New York -7.4 -4.8 -13.2 -8.8
North Carolina +4.5 +22.0 +15.8 -5.1
North Dakota -20.2 -7.2 -15.5 -9.0
Ohio -2.2 -0.3 +7.1 +7.5
Oklahoma +0.1 -10.8 -17.3 -7.3
Oregon -5.9 -8.6 -5.9 +3.0
Pennsylvania +9.3 +1.6 -5.1 -6.6
Rhode Island +6.9 +18.3 +19.2 +0.8
South Carolina -5.2 -8.6 -6.6 +2.1
South Dakota -10.0 -3.3 -1.9 +1.5
Texas +13.4 +0.4 -4.6 -4.9
Vermont -3.3 -4.3 -10.3 -6.3
Virginia -3.7 -4.2 -9.9 -6.0
Washington -1.1 -12.1 -13.2 -1.2
West Virginia -4.7 -2.5 -10.6 -8.3
Wisconsin -5.7 -12.9 -13.7 -0.8
Wyoming -8.2 -7.4 -16.4 -9.7
SOURCE: Mathematica analysis of 2001-2002 and 2006-2007 MAX data for 41 states with representative FFS nursing home data in 2001-2002 and representative FFS nursing home and ICF/IID data in 2006-2007 (excludes data from Arizona, District of Columbia, Hawaii, Indiana, Maine, Michigan, Minnesota, New Hampshire, Tennessee, and Utah).
NOTE: New spells are spells beginning between July 1, 2001, and December 31, 2002 (for 2001-2002 data) and between July 1, 2006, and December 31, 2007 (for 2006-2007 data). Total number of enrollees and enrollees with nursing home spells were also measured during these 18-month periods only and not during the full 2-year period.

States that allocated a relatively high proportion of their Medicaid LTC expenditures to HCBS experienced declines in the percentage of elderly or disabled enrollees who resided in nursing homes or had new spells of care, whereas those that allocated less to HCBS generally saw increases. Kaye et al. (2009) defined high-HCBS states as states that allocated more than the median proportion of Medicaid LTC spending to HCBS in 2005 and low-HCBS states as states that allocated less than the median.7 The percentage of aged or disabled enrollees with nursing home spells declined 3 percent in high-HCBS states from 2001-2002 to 2006-2007, compared with a 4 percent increase in low-HCBS states (data not shown). Although spending on HCBS is only one factor potentially driving changes in nursing home utilization, it is possible that declining rates of nursing home utilization in the group of high-HCBS states were partly the result of a greater orientation toward provision of community-based services.

3. Who Used Nursing Home Care?

As expected, enrollees with new spells of nursing home care were likely to be older, White women. Approximately 28 percent were at least 85 years old, with an additional 31 percent between ages 75 and 84 (Table II.3). The vast majority of all other enrollees with new nursing home spells were between ages 45 and 64. Three-quarters were White, and slightly less than two-thirds were female.

TABLE II.3. Characteristics of Aged or Disabled Enrollees with New Medicaid-Financed Nursing Home Spells Between July 2006 and December 2007
Characteristic   Number or Percentage  
Number of enrollees with new spells in all states 694,111
   Percentage female 64.9
   Percentage non-Hispanic White 75.0
Age (percentage of subgroup)
   Under age 21 0.3
   21-44 years 4.5
   45-64 years 19.4
   65-74 years 17.0
   75-84 years 31.1
   85 years and older 27.7
Percentage with multiple new spells 6.1
Percentage with spells in both nursing homes and ICFs/IID   0.1
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.

Relatively few enrollees with new nursing home stays (6 percent) had multiple spells of care during the 18-month study period window. Thus, there is little evidence in these data of a pattern of multiple admissions or "frequent flyer" care that could suggest quality problems.

4. How Did Enrollees Residing in Nursing Homes Become Eligible for Medicaid?

Because nursing home care is expensive, many nursing home residents who did not qualify for Medicaid prior to admission qualify at some point during their stay as they spend down their assets to pay for care. Other residents, however, received Medicaid services prior to the beginning of their spell, perhaps qualifying under a different maintenance assistance status (MAS). To understand how nursing home residents qualified for care, we examined their MAS both two months prior to and at the beginning of their Medicaid-financed nursing home stays. Individuals may qualify for full Medicaid benefits according to cash assistance-related, medically needy, poverty-related, Section 1115 demonstration waiver-related, or other eligibility criteria. Those qualifying under cash assistance-related criteria generally have incomes below the Supplemental Security Income (SSI) standard. The "other" category includes individuals who qualify under the 300 percent rule, which permits persons with a level of need requiring institutionalization to qualify for Medicaid services if their income is less than 300 percent of the SSI standard. Many states have medically needy programs, in addition to or instead of the 300 percent rule, which allow individuals with higher incomes to "spend down" to Medicaid eligibility levels by offsetting their incomes against the costs of institutional care.8

We found that, in most states, more enrollees qualified for Medicaid services during the first month of their Medicaid-financed spell via the "other" MAS than any other eligibility category. In 34 of 45 states, "other" was the most common eligibility category, with at least 70 percent of all enrollees receiving benefits under this status in 23 states, and at least 50 percent receiving benefits under this status in 30 states (Table II.4). For all states together, roughly half of all enrollees qualified for benefits through the "other" category, compared with 22 percent who qualified via the cash assistance criterion and 21 percent who qualified through a medically needy program. Of the 34 states in which "other" was the most common way of qualifying for benefits, 30 had adopted the 300 percent rule, making it likely that many of the "other" enrollees actually qualified via this rule.9

After "other" criteria, most enrollees qualified via the medically needy or cash assistance pathways. Medically needy classifications were the most common pathway to benefits in nine states, with at least two-thirds of all enrollees who qualified for benefits qualifying under a medically needy program in seven of these states. Cash assistance recipients were the most common qualifying group in two of the states but the second most common group in 37 other states. Although poverty-related expansions were not the most common pathway to eligibility in any state, qualifying via poverty-related criteria was more common in states that had adopted poverty-related expansions to Medicaid eligibility but not the 300 percent rule, such as Hawaii, Massachusetts, and North Carolina.

TABLE II.4. MAS in First Month of First New Medicaid-Financed Nursing Home 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
  Nursing Home Spells  
Percentage in MAS Group at Start of Spell
  "Other"   Cash
  Assistance-Related  
  Medically Needy     Poverty-Related   Section 115
  Demonstration Waiver  
"Other"
   Iowabc 8,416 94.1 5.5 0.1 0.1 0.0
   Wyomingc 1,075 89.2 9.3 0.0 1.4 0.0
   Ohiod 44,485 86.7 9.0 0.0 4.3 0.0
   Kansasbc 7,370 86.6 11.5 0.8 1.1 0.0
   Tennesseeabc 16,543 86.2 11.6 0.4 1.7 0.0
   Missourid 19,985 85.0 14.7 0.0 0.3 0.0
   Louisianabc 14,396 84.0 10.6 5.2 0.2 0.0
   South Dakotac 2,647 82.2 15.2 0.0 2.6 0.0
   Georgiaabc 16,594 81.6 17.9 0.1 0.3 0.0
   South Carolinac 8,101 81.4 9.0 0.0 9.6 0.0
   Oregonc 6,725 80.3 18.5 0.0 1.0 0.0
   Delawarec 1,653 79.0 18.7 0.0 2.2 0.1
   Oklahomacd 10,655 78.1 9.5 0.0 12.2 0.0
   Washingtonbc 11,483 77.3 11.3 10.2 0.6 0.0
   Connecticutbd 14,254 76.5 6.7 15.8 0.9 0.0
   Idahoc 2,576 76.1 23.6 0.0 0.3 0.0
Pennsylvaniabc 37,591 74.5 11.7 10.6 3.2 0.0
   Virginiabcd 13,260 73.2 17.4 6.9 2.5 0.0
   Texasc 45,736 72.9 26.1 0.0 0.9 0.0
   New Mexicoc 2,936 72.3 25.8 0.0 1.9 0.0
   Arkansasbc 7,731 71.8 23.6 0.4 3.9 0.0
   West Virginiabc 5,259 70.8 17.5 10.6 1.1 0.0
   Wisconsinbc 15,557 70.1 15.2 12.5 1.9 0.4
   Nevadac 2,606 69.1 27.7 0.0 3.1 0.0
   Floridabc 36,996 65.4 25.8 0.3 6.6 1.7
   New Jerseybc 20,008 65.2 15.7 13.2 5.9 0.0
   Vermontbc 1,840 64.7 17.1 17.1 0.0 1.0
   Alabamac 10,706 63.1 28.4 0.0 8.5 0.0
   Mississippic 10,682 62.0 35.4 0.0 2.5 0.2
   Coloradoc 7,407 55.1 44.5 0.0 0.3 0.0
   All States 694,111 49.7 22.1 21.1 6.9 0.2
   Kentuckybc 15,676 48.9 39.3 10.6 1.1 0.0
   Michiganbc 22,790 47.8 14.8 12.1 25.2 0.0
   Rhode Islandabc 4,360 45.5 22.3 32.0 0.2 0.0
    Massachusettsb 28,055 30.0 27.3 14.5 26.2 2.0
Medically Needy
   North Dakotabd 2,201 0.2 12.4 86.6 0.8 0.0
   Marylandbc 10,880 0.3 14.4 84.9 0.4 0.0
   Montanab 2,404 9.3 18.1 72.5 0.0 0.0
   New Yorkb 60,324 0.6 28.9 68.8 1.3 0.2
   District of Columbiab   1,461 4.6 23.1 68.4 3.8 0.0
   Nebraskab 5,888 0.1 17.5 67.1 15.3 0.0
   Illinoisbd 38,558 14.4 11.7 65.7 8.2 0.0
   North Carolinab 22,570 0.0 20.9 44.3 34.8 0.0
   Hawaiibd 2,268 0.2 29.0 36.6 33.4 0.7
Cash Assistance
   Alaskac 815 28.1 71.5 0.0 0.2 0.0
   Californiab 70,588 3.0 47.8 37.3 11.9 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).
NOTES: New spells are spells beginning on or after July 1, 2006. 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.

Prior to the beginning of the first spell of nursing home care, roughly three of every ten individuals who would ultimately receive Medicaid-financed nursing home care were not enrolled (Table II.5), with unenrolled individuals accounting for the plurality of persons with new spells in 22 of 45 states. This suggests that many individuals with new spells qualified for Medicaid for the first time because they required costly nursing home care. Because we considered only Medicaid-financed new spells in this analysis, it is highly likely that some individuals who were unenrolled two months prior to the beginning of their spell were actually residing in a nursing home at the time but did not yet qualify for Medicaid.

TABLE II.5. MAS in the Two Months Preceding the First New Medicaid-Financed Nursing Home 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  
Not Enrolled
   Montanab 2,404 53.0 7.7 15.8 18.1 0.0 0.0
   North Dakotabd 2,201 49.1 0.2 13.9 25.5 6.0 0.0
   Wyomingc 1,075 45.9 33.0 9.6 0.0 5.6 0.0
   Pennsylvaniabc 37,591 45.5 23.9 14.5 3.0 8.3 0.0
   Delawarec 1,653 45.0 19.1 17.0 0.0 14.9 0.5
   South Dakotac 2,647 44.7 20.7 19.9 0.0 10.2 0.0
   Marylandbc 10,880 43.3 1.9 17.3 27.7 5.3 0.3
   Kansasbc 7,370 40.8 37.4 11.4 2.7 3.5 0.0
   Iowabc 8,416 40.8 37.6 10.8 3.0 3.3 0.1
   Michiganbc 22,790 39.9 16.0 15.6 5.9 18.3 0.1
   Rhode Islandabc 4,360 39.7 22.8 22.7 7.5 3.4 0.0
   New Jerseybc 20,008 39.2 29.4 16.7 3.3 6.9 0.0
   West Virginiabc 5,259 39.1 30.5 16.7 3.9 5.4 0.0
   Oklahomacd 10,655 36.8 30.3 13.6 0.0 15.1 0.0
   Floridabc 36,996 36.4 21.5 24.6 0.7 11.4 0.9
   Nebraskab 5,888 36.3 0.1 17.0 20.7 22.4 0.0
   Coloradoc 7,407 35.0 24.7 34.9 0.0 2.0 0.0
   New Mexicoc 2,936 34.1 29.7 27.5 0.0 4.5 0.0
   Arkansasbc 7,731 33.9 29.8 24.1 0.4 7.3 0.0
   Wisconsinbc 15,557 33.9 22.3 15.0 4.4 3.5 17.6
   Massachusettsb 28,055 32.4 8.2 26.9 7.7 19.3 2.4
   All States 694,111 31.4 22.2 23.7 9.4 9.4 0.6
   Hawaiibd 2,268 30.8 0.1 27.8 11.9 25.7 0.8
"Other"
   Ohiod 44,485 35.8 47.0 8.4 0.0 5.3 0.0
   Tennesseeabc 16,543 28.7 46.1 16.8 0.8 4.7 0.0
   Missourid 19,985 32.5 45.3 17.8 0.0 1.0 0.0
   Washingtonbc 11,483 29.7 43.1 16.0 5.1 2.8 0.0
   South Carolinac 8,101 25.8 42.4 16.3 0.0 12.7 0.0
   Idahoc 2,576 32.2 42.2 18.7 0.0 3.3 0.0
   Oregonc 6,725 30.7 40.5 18.9 0.0 6.3 0.2
   Connecticutbd 14,254 31.4 40.4 9.7 9.9 5.1 0.0
   Georgiaabc 16,594 30.3 40.4 19.2 0.2 7.2 0.0
   Virginiabcd 13,260 28.9 38.4 20.1 3.7 6.3 0.0
   Nevadac 2,606 29.5 37.0 24.4 0.0 5.7 0.0
   Louisianabc 14,396 32.9 36.7 16.1 1.5 9.8 0.0
   Texasc 45,736 28.6 30.8 26.9 0.0 10.6 0.0
   Vermontbc 1,840 23.6 27.1 17.2 18.4 0.2 11.0
Cash Assistance
   Alaskac 815 15.2 9.7 72.1 0.0 0.9 0.0
   Californiab 70,588 20.5 2.7 47.5 14.8 12.4 0.0
   Kentuckybc 15,676 24.6 25.8 38.9 4.4 3.8 0.0
   New Yorkb 60,324 31.4 0.7 35.5 26.2 1.9 0.5
   Mississippic 10,682 19.4 21.7 35.3 0.0 20.8 0.9
   Alabamac 10,706 29.9 11.7 34.5 0.0 20.0 0.0
   District of Columbiab   1,461 19.4 8.8 29.8 25.1 13.3 0.1
   North Carolinab 22,570 24.4 0.0 27.1 19.6 26.5 0.0
Medically Needy
   Illinoisbd 38,558 17.7 13.2 11.6 45.0 10.6 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 Alaska, Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTES: New spells are spells beginning on or after July 1, 2006. 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.

Other individuals did qualify for Medicaid benefits prior to the beginning of their spells, however, indicating that these individuals were living in the community or residing in hospitals in the two months prior to their first new spell. In 14 states, the plurality of individuals who would eventually have new spells qualified for Medicaid via the "other" pathway, while in eight other states, the plurality qualified via the cash assistance pathway. Some of the individuals who qualified via the "other" criteria likely qualified through their participation in an HCBS waiver program. However, since coverage is retroactive up to three months prior to application for benefits, it is likely that some individuals qualified for benefits upon admission and are reported in the data as Medicaid enrollees in the two months prior to admission only because Medicaid retroactively covered their unpaid medical bills.

The vast majority of individuals who were not enrolled in Medicaid prior to their first new spell of Medicaid-financed nursing care qualified for benefits during their stay either through the "other" channel (63 percent) or a medically needy program (30 percent) (Table II.6). It is likely that these individuals' incomes were sufficiently high that they could only qualify for benefits under the 300 percent rule or by spending down to eligibility levels.

TABLE II.6. Transitions in MAS at the Start of first New Medicaid-Financed Nursing Home Spells Between July 2006 and December 2007
  Number in MAS
  Group 2 Months Before  
Start of Spell
Percentage in MAS Group at Start of Spell
  "Other"   Cash
  Assistance-Related  
  Medically Needy     Poverty-Related   Section 115
  Demonstration Waiver  
Not Enrolled 217,766 63.2 3.0 30.0 3.7 0.2
"Other" 153,993 96.0 1.5 1.1 1.3 0.0
Cash Assistance-Related 164,737 8.8 86.1 3.9 1.2 0.0
Medically Needy 65,009 4.1 1.5 93.2 1.3 0.0
Poverty- Related 65,077 38.4 1.2 7.8 52.4 0.2
Section 1115 Demonstration Waiver   4,481 66.1 3.3 8.5 2.6 19.5
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.

The majority of those who qualified for full-benefits before admission to the nursing home continued to qualify under the same eligibility criteria once admitted, reflecting their low-income. Among those previously enrolled individuals whose status changed upon admission, approximately two-thirds qualified at the beginning of their Medicaid-financed stay under the "other" eligibility criteria.10

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