An Improved Method for Classifying HCBS Service Use and Expenditures: The HCBS Taxonomy September 10, 2013 Ralph Lollar, Victoria Peebles, Dan Timmel National Home- and Community-Based Services Conference
Today s Presentation Introduction Importance of the taxonomy History and development of the taxonomy Results from the Medicaid Analytic extract (MAX) 2010 Next steps and questions 2
Introduction 3
Importance of the Taxonomy 4
Purpose of HCBS Taxonomy State flexibility in waivers and state plan amendments creates variation in services and supports in claims data Variation in terminology and procedure codes make it difficult to know what is happening with HCBS at a national level Measuring what occurs is necessary to demonstrate the effectiveness of HCBS The HCBS taxonomy creates an orderly classification of services so the Centers for Medicare & Medicaid Services (CMS) and researchers can aggregate data The taxonomy classifies, but does not limit, state service definitions 5
Uses of the HCBS Taxonomy The taxonomy can be used in a variety of analyses, such as Which states provide a particular service? How many people use a service or group of services? How much does a state spend on a particular service and how does this compare to other states? What services are provided under state waivers? Ruttner & Irvin used the taxonomy to analyze personal care services provided under waivers and state plans (2013) 6
HCBS Taxonomy Development 7
History Version 1 Developed in 2009 by Thomson Reuters (now Truven Health Analytics) using previous research and an analysis of service definition text from 159 waiver programs Tested and reviewed by stakeholders Feedback indicated Version 1 lacked a clear categorization structure 8
History Version 1 (cont.) 9
History Version 2 Developed jointly by Truven Health Analytics and Mathematica and submitted in April 2011 Truven Health proposed a categorization scheme based on common instances where two or more taxonomy services were in a single service entry in the Waiver Management System Mathematica applied Version 2 to 2008 Medicaid Statistical Information System (MSIS) claims data for 1915(c) waivers and recommended fewer services and a categorization scheme Subsequent revisions reflected additional feedback from CMS, state associations, and a 2012 pilot with state and CMS staff 10
History Version 2 in 2008 MSIS Data Version 2 was applied to 2008 MSIS waiver claims data To document processes and procedures for allocating claims To characterize Medicaid HCBS expenditures under waivers and state plans Results Most waiver expenditures allocated to round-the-clock services, followed by home care and day services Unable to classify only 7 percent of waiver expenditures An improvement over the 80 percent in MSIS and the 37 percent in MAX classified as "other" type of service (TOS) Claims reporting varies by state and affected our ability to classify services, but taxonomy facilitates understanding of state-specific codes 11
Taxonomy Categories 1. Case management 2. Round-the-clock services 3. Supported employment 4. Day services 5. Nursing 6. Home-delivered meals 7. Rent and food expenses for live-in caregiver 8. Home-based services 9. Caregiver support 10. Other mental health and behavioral services 11. Other health and therapeutic services 12. Services supporting participant direction 13. Participant training 14. Equipment, technology, and modifications 15. Non-medical transportation 16. Community transition 17. Other services 18. Unknown 12
Results from MAX 2010 13
MAX 2010 Research-friendly Medicaid administrative files with information on eligibility, service use, and payments Advantages of the HCBS taxonomy in MAX Stakeholder-approved categories Consistent definition across all 51 states, even if they use a different name for the service Accounts for national and state-specific service codes More specific than MSIS TOS More nuanced and more meaningful to researchers 14
HCBS Conception to Implementation Examine service code, service code flag, service code modifier, MSIS TOS, MAX TOS, place of service Assign HCBS taxonomy When in doubt, consult state documentation, websites, and staff; Truven Health; and other stakeholders 15
HCBS Implemented in MAX 2010 (1) National HCPCS E0100 E0159 (cane, crutches, walkers) equipment and technology National CPT code 99509 (home visit for assistance with activities of daily living and personal care) personal care 16
HCBS Implemented in MAX 2010 (2) National codes with state s differentiation MN-T2017 (Habilitation, residential, waiver; 15 minutes), modifier U9 shared living, residential habilitation MT-T2016 (Habilitation, residential, waiver; per diem), place of service = group home group living, residential habilitation State codes LA-Z0060 (Environmental modifications lift) home accessibility and/or vehicle accessibility 17
Approach Reviewed claims data for each of the 28 approved states in MAX Analyzed the proportion of claims mapped to the unknown taxonomy category compared to claims originally mapped to the unknown or other TOS in MAX Analyzed expenditures and the number of users for 1915(c) waiver recipients across each HCBS taxonomy service and category 18
Results in MAX 2010 In 2010, 28 states spent almost $23.6 billion on HCBS We mapped 97 percent of expenditures to an HCBS taxonomy category The MSIS TOS field categorized only 20 percent of claims The MAX TOS field categorized 71 percent of claims 19
Use of HCBS Of more than 850,000 Medicaid waiver participants across 28 states, no one type of HCBS was used by the majority or participants HCBS Taxonomy Category Case management Home-based Equipment, technology, and modifications Day services Round-the-clock Caregiver support Nonmedical transportation Home-delivered meals Mental health Unknown Other health Nursing Participant training Supported employment Participant direction Other services Community transition Live-in caregiver 0 5 10 15 20 25 30 35 40 45 50 Waiver use (percentage) Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010 20
HCBS Expenditures Three of the 18 HCBS categories round-the-clock, home-based, and day services accounted for nearly 80 percent of all waiver expenditures Unknown (3%) Mental health (3%) Case management (4%) All others (11%) Day services (15%) Round the clock (46%) Home based (18%) Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010 21
Round-the-Clock Services: Total 1915(c) Waiver Amount Paid Expenditures ($) 450,000,000 400,000,000 350,000,000 300,000,000 250,000,000 200,000,000 150,000,000 100,000,000 50,000,000 0 Alabama Alaska Delaware Indiana Iowa Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010 22
Round-the-Clock-Services: Average Amount Paid Average Amount Paid per User ($) 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 Alabama Alaska Delaware Indiana Iowa Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010 23
Round-the-Clock vs. Home-Based Services by State Percentage of State Expenditures 100 90 80 70 60 50 40 30 20 10 0 State Round-the-Clock Round-the-clock Home-Based Home-based services Services Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010 24
Number of States Reporting Waiver Claims HCBS Taxonomy Category Equipment, Technology, and Modifications Home-Based Caregiver Support Day Services Round-the-Clock Case Management Mental Health Unknown Other Health Nonmedical Transportation Supported Employment Nursing Home-Delivered Meals Participant Training Other Services Community Transition Participant Direction Live-In Caregiver 0 5 10 15 20 25 30 Number of States Reporting Waiver Claims Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010 25
Average Paid per User HCBS Taxonomy Category Round-the-Clock Services Total Day Services Home-Based Services Participant Training Other Mental Health Supported Employment Unknown Nursing Services Supporting Participant Direction Other Caregiver Support Case Management Nonmedical Transportation Other Health and Therapeutic Services Community Transition Services Home-Delivered Meals Equipment, Technology, and Modifications 0 10,000 20,000 30,000 40,000 50,000 60,000 Average Paid per User ($) Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010 26
Next Steps 27
MAX 2010 Timeline MAX 2010 production began in April 2012 Data available for 36 states Data for the 15 remaining states is contingent on the states submission of their MSIS files 28
Quality of State s Data Is Important Use national service codes when possible Use state-specific service codes as needed (please be specific in your service definitions) Waiver enrollment and waiver services should align Be thoughtful about MSIS TOS Place of service helps to differentiate Assisted living from other types of residential services In-home respite from out-of-home respite 29
How States Can Improve Their Data Use specific national HCPCS codes Choose Assisted living, adult foster care, supported living, and group living 24-hour private-duty nursing and short-term skilled nursing In-home respite and out-ofhome respite Specific assistive technologies, supplies, and home adaptations Instead of Residential habilitation or general residential Unspecified nursing care Respite in unspecified location Unspecified personal items, miscellaneous therapeutic items and supplies, or supplies not otherwise specified 30
Next Steps for the Taxonomy Implementation in the new expanded version of MSIS, the Transformed Medicaid Statistical Information System (T-MSIS) States will begin reporting the taxonomy in T-MSIS Integration into the CMS electronic system for 1915(c) waiver applications in the future 31
Acknowledgements Truven Health Analytics Steve Eiken Mathematica Policy Research Alex Bohl Carol Irvin Julie Sykes Centers for Medicare & Medicaid Services Cara Petroski, Project Officer 32
For More Information Victoria Peebles, Mathematica Policy Research vpeebles@mathematica-mpr.com Ralph Lollar, CMS ralph.lollar@cms.hhs.gov Dan Timmel, CMS daniel.timmel@cms.hhs.gov MAX website www.cms.gov/research-statistics-data-and-systems/ Computer-Data-and-Systems/ MedicaidDataSourcesGenInfo/MAXGeneralInformation.html Research data assistance center www.resdac.org 33