This report draws on MAX data to construct a profile of Medicaid enrollees and their Medicaid-financed institutional stays (also referred to as spells) in 2006 and 2007.2 We included in our sample enrollees who were elderly or entitled on the basis of disability to full-benefits and began spells of Medicaid-financed institutional care in the latter half of 2006 or in 2007. Because some disabled enrollees qualify for benefits on a basis other than disabled, it is important to note that references to disabled enrollees in this report indicate only those enrollees with a basis of eligibility (BOE) code in the MAX data corresponding to the disabled group. The first six months of 2006 were reserved as a look-back period, allowing us to examine aspects of enrollees' experience prior to their Medicaid-financed spell of institutional care.3 The sample included any individual with a Medicaid-financed nursing home stay during this period; consequently, our analysis reflects the experience of both LTC users and those receiving post-acute care.
To construct spells of care, we examined the beginning and end dates of claims for nursing home and ICF/IID services contained in the MAX Long-Term Care (LT) file. Because a spell of LTC can be interrupted by a hospitalization or for other reasons, we defined "new" spells of care conservatively: a claim for institutional services was interpreted as triggering the beginning of a new spell only if the individual to whom the services were provided did not incur a claim for the same type of institutional service (for example, nursing home or ICF/IID) in the two months prior to the beginning of the claim. In doing so, we followed the definition of a spell adopted by Wenzlow et al. (2008) in their earlier work. However, improvements in the MAX data and our methodology limit the extent to which we can make direct comparisons with the earlier results.
An important implication of our definition of spells is that an individual's actual nursing home stay in many cases began prior to the Medicaid-financed portion, as commonly occurs when an individual enters a nursing home as a private payer but then spends down her income and assets to Medicaid eligibility levels. For example, an individual who resided in a nursing home from November 1, 2006, through June 30, 2007, but who had Medicaid claims for nursing home services only from June 1, 2007, through June 30, 2007, would only be considered to have had a one-month (Medicaid-financed) spell of nursing home care in our analysis, even though that individual was actually institutionalized for eight months.
We included in the analysis only those states with fee-for-service (FFS) data that are both complete and believed to be reliable. Six states were excluded from all analyses: Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah. In addition, analyses of state policy variables, several of which related to HCBS spending and utilization at the state level, excluded seven other states that are believed to have unreliable HCBS data: Massachusetts, Michigan, Montana, Oregon, Pennsylvania, Rhode Island, and Texas.
A more detailed discussion of the MAX data and methods used to construct the analytic file and perform the analysis, along with their limitations, is in Appendix B.
In the following chapters, we separately discuss the characteristics of nursing home (Chapter II) and ICF/IID (Chapter III) residents and their Medicaid-financed spells of care. We also examine in each chapter how the percentages of stays that are very short (less than three months) or very long (more than one year) vary across states with changes in policy-related variables such as the percentage of enrollees of Medicaid-financed LTC who used HCBS. In Chapter IV, we discuss policy implications and directions for future research.