MEDICAID EXPENDITURES FOR LONG-TERM SERVICES AND SUPPORTS: 2011 UPDATE

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1 RESEARCH PAPER MEDICAID EXPENDITURES FOR LONG-TERM SERVICES AND SUPPORTS: 2011 UPDATE STEVE EIKEN, KATE SREDL, BRIAN BURWELL, AND LISA GOLD THOMSON REUTERS 150 CAMBRIDGEPARK DRIVE CAMBRIDGE, MA OCTOBER 31, 2011

2 TABLE OF CONTENTS s in Data... 1 Description of Data Tables... 2 Trends in Total LTSS... 4 LTSS age of Total Medicaid... 5 Non-Institutional Services age of Total LTSS... 6 LTSS by Medicaid Program Authority... 7 Variation by Population Served... 8 Use of Prior Period Adjustments Caveats Appendix A: National Data Tables Appendix B: State Data Tables The opinions expressed in this report are those of the authors and do not reflect the views of Thomson Reuters.

3 MEDICAID EXPENDITURES FOR LONG-TERM SERVICES AND SUPPORTS This document is the latest in a series of spending reports on Medicaid long-term services and supports (LTSS). 1 This year s report contains newly available data and changes in the services that are included within LTSS. We explain these changes, summarize the data, and describe national trends regarding the following topics: 1. The rate of increase in Medicaid LTSS expenditures 2. The percentage of total Medicaid spending used for LTSS 3. The non-institutional portion of Medicaid LTSS expenditures 4. Medicaid LTSS spending by program authority 2 5. The variation in the non-institutional percentage of Medicaid LTSS by population served. CHANGES IN EXPENDITURES DATA We have made significant changes from previous reports to provide more complete information. First, this report includes two types of Medicaid LTSS expenditures data that were previously unavailable: State-reported data for LTSS provided through managed care organizations that are not identifiable in the state CMS 64 reports. These data are fully explained in a separate Thomson Reuters report. 3 Data for the following Medicaid program authorities, which were identified in CMS 64 reports for the first time: o Rehabilitative services o Private duty nursing o State plan home and community-based services (HCBS) that are authorized under Section 1915(i) of the Social Security Act 1 Previous reports in this series referred to long-term care expenditures. Starting this year, we use the phrase long-term services and supports because it is a more inclusive term for the range of long-term assistance provided to older adults and people with disabilities. 2 Program authorities include Medicaid State Plan services specified in Section 1905(a) of the Social Security Act and other options that allow additional state-defined services if specific requirements are met such as waivers authorized under Sections 1115 and 1915(c) of the Social Security Act. 3 Kasten J, Eiken S, Burwell B. Medicaid Managed Long-Term Services and Supports. Thomson Reuters: April 6, 2011, available at (Accessed on May 5, 2011). Medicaid for Long-Term Services and Supports 1

4 o Self-directed personal assistance services that are authorized under Section 1915(j) of the Social Security Act. Second, we included more program authorities within LTSS to align with the Balancing Incentive Payments Program service categorization. 4 LTSS now include services provided in mental health facilities (also known as institutions for mental disease) and the four newly available program authorities identified above. Future versions of these reports will include the State Plan options for Health Homes and Community First Choice, which were authorized in the Affordable Care Act. DESCRIPTION OF DATA TABLES Appendix A and B present a series of data tables showing FY 2005 through FY 2010 Medicaid LTSS expenditures. Most data are based on CMS 64 reports, which states submit to the Centers for Medicare & Medicaid Services (CMS) to claim Federal financial participation (FFP). The CMS 64 reports are among the more reliable sources of state Medicaid spending because the Federal government audits these reports. However, the CMS 64 reports do not consistently identify LTSS provided through managed care programs. Thomson Reuters contacted states to collect FY 2008 and LTSS spending data that were not identified in the CMS 64 reports. 5 In all tables, FY 2010 data are labeled preliminary expenditures to reflect the likelihood that national totals, and data for several states, will change. FY 2010 data do not include state-reported managed care expenditures and prior period adjustments submitted in the CMS 64 in FY 2011 and subsequent years (see the section entitled Use of Prior Period Adjustments in this report). The preliminary FY 2010 spending figure for Medicaid LTSS ($125.8 FY 2010 data are labeled expenditures to reflect the likelihood that data for several states will change. We expect the preliminary FY 2010 expenditures figure ($125.8 billion) to increase by at least $6 billion. 4 The categories of service in this report do not match perfectly with the definitions of institutional LTSS and non-institutional LTSS used in the Balancing Incentive Payments Program application announcement because data for some services are not available in the CMS 64 reports. A state may provide more detailed data for the purposes of determining Balancing Incentive Payments Program eligibility. See the Balancing Incentive Payments Program application announcement released with a September 12, 2011 State Medicaid Director letter, available at (Accessed on September 14, 2011). 5 Kasten J, Eiken S, Burwell B. Medicaid Managed Long-Term Services and Supports. Thomson Reuters: April 6, 2011, available at (Accessed on May 5, 2011). Medicaid for Long-Term Services and Supports 2

5 billion) is likely to increase by more than $6 billion (five percent) when all data are included. Table 1 in Appendix A shows national spending data for LTSS program authorities. We present state data in Tables A through AE. Three tables summarize data that are reported on other tables: Institutional LTSS (Table E) are the sum of: o Nursing homes (Table A) o Intermediate care facilities for people with mental retardation (ICF/MR; Table B) 6 o Mental health facilities regular payments (Table C) o Mental health facilities disproportionate share payments (Table D). Non-institutional LTSS (Table P) are the sum of: o Waivers authorized under Section 1915(c) of the Social Security Act (Table F) o Personal care (Table G), which includes the Texas Community Assistance Services program authorized under Section 1929 of the Social Security Act 7 o Home health (Table H) o HCBS authorized under Section 1115 or Section 1915(a) of the Social Security Act (Table I) o Program of All-Inclusive Care for the Elderly (PACE; Table J) o Rehabilitative services (Table K) o Private duty nursing (Table L) o State plan HCBS authorized under Section 1915(i) of the Social Security Act (Table M) o Self-directed personal assistance services authorized under Section 1915(j) of the Social Security Act (Tables N and O). 8 Total LTSS (Table Q) are the sum of institutional LTSS (Table E) and noninstitutional LTSS (Table P). 6 We prefer to use the phrase intellectual disability instead of mental retardation. However, when describing ICF/MR, we use the name in Federal law and regulation. 7 Section 1929 allows states that meet certain criteria to provide an entitlement to home and communitybased services and no other Medicaid services for people with incomes under 300 percent of the Supplemental Security Income benefit who do not qualify for the full Medicaid benefit. Texas offers personal care under Section 1929 and is the only state that has used this section. 8 The CMS 64 form provides two categories for services authorized under Section 1915(j): one for services that are an alternative to a 1915(c) waiver (Table N) and one for services that are an alternative to a State Plan personal care service (Table O). Data for FY 2005 through on Tables N and O include selfdirected services programs that started as Section 1115 waivers before Congress passed Section 1915(j). Medicaid for Long-Term Services and Supports 3

6 In Tables A through AE, the per State Resident column shows Medicaid expenditures divided by the total state population according to the U.S. Census Bureau. We used data from the 2010 Census for FY We used the most recent release of current population estimates for FY 2008 and. 10 Tables A through AE rank states from highest to lowest expenditures for three years (FY 2008,, and FY 2010). States are arranged in order of their ranking. Tables AF, AG, and AH present the percentage of LTSS expenditures allocated to noninstitutional LTSS for all services (Table AF), services for older adults and people with physical disabilities (Table AG), and services for people with developmental disabilities (Table AH). We ranked states for FY 2008,, and FY 2010 from highest to lowest non-institutional percentage, and show states in order of their ranking. Appendix B displays the above data by state. Tables 1 through 51 provide one table for each state and the District of Columbia. TRENDS IN TOTAL LTSS EXPENDITURES When discussing spending trends, we focus on data through because FY 2010 data do not include managed care expenditures and prior period adjustments in several states. Reported Medicaid LTSS expenditures were $127.1 billion, an increase of 5.5 percent over FY This increase was similar to the 4.9 percent average annual spending increase between FY 2005 and FY These percentages slightly overstate the increase in expenditures because we only included state-reported managed care data for FY 2008 and. For example, without state-reported managed care data, expenditures would have increased 4.5 percent in and an average of 3.8 percent from FY 2005 to FY Medicaid LTSS expenditures growth has slowed since the early 2000s, when spending increased an average of seven percent per year (See Figure 1 on the following page). 9 U.S. Census Bureau, Population Division Table 2. Comparison of Population Estimates and Census Counts for the United States, Regions, States, and Puerto Rico: April 1, 2010 February 2011, available at (Accessed on September 2, 2011). 10 U.S. Census Bureau, Population Division Table 1. Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2000 to July 1, 2010 (NST- PEST ) February 2011, available at (Accessed on September 2, 2011). Medicaid for Long-Term Services and Supports 4

7 Figure 1: Medicaid LTSS Growth: Annual Average Growth in Five-Year Periods from and LTSS PERCENTAGE OF TOTAL MEDICAID LTSS accounted for 34.5 percent of total Medicaid expenditures in. LTSS has been percent of total Medicaid spending since FY 2003 (See Figure 2 on the following page). The inclusion of mental health facilities within LTSS added two percentage points to the LTSS share of total Medicaid spending each year from FY 2006 through and three to four percentage points in earlier years. 11 Reported total Medicaid expenditures were $368.3 billion in, which is an increase of 9.3 percent from FY Total Medicaid expenditures grew at a higher rate than in previous years, reflecting increased enrollment of families with children during the recession With one exception, data for 2009 and earlier years were not available for the other new services included within LTSS. CMS 64 data are available for five self-directed services programs that were authorized under Section 1115 waivers before Section 1915(j) was an option. These programs include the original Cash and Counseling states (Arkansas, Florida, and New Jersey) and similar programs in Colorado and Oregon. 12 Holahan J, Clemans-Cope L, Lawton E, Rousseau D. Medicaid Spending Growth over the Last Decade and the Great Recession, Kaiser Commission for Medicaid and the Uninsured: February 2011, available at (Accessed on February 23, 2011). Medicaid for Long-Term Services and Supports 5

8 Figure 2: LTSS age of Total Medicaid, NON-INSTITUTIONAL SERVICES PERCENTAGE OF TOTAL LTSS Spending for non-institutional LTSS rose to 44 percent of all Medicaid LTSS expenditures. As shown in Figure 3 on the following page, this distribution has increased one to three percentage points each year since 1995 as states have invested more resources in alternatives to institutional services. The inclusion of mental health facilities reduced the non-institutional share of LTSS by two to three percentage points each year since Medicaid for Long-Term Services and Supports 6

9 Figure 3: Non-Institutional LTSS as a age of Total Medicaid LTSS, LTSS EXPENDITURES BY MEDICAID PROGRAM AUTHORITY States have several options, collectively called program authorities, to include LTSS within the Medicaid program. We list Medicaid LTSS expenditures by program authority below, starting with institutional services. Institutional LTSS spending increased 2.2 percent, from $69.7 billion in FY 2008 to $71.2 billion in. Institutional LTSS included the following: Nursing homes ($51.3 billion, a 2.5 percent increase) ICF/MR ($13.3 billion, a 2.7 percent increase) Fee-for-service payments for mental health facilities ($3.3 billion, a 2.5 percent decrease) Disproportionate share hospital payments for mental health facilities ($3.3 billion, a 0.5 percent decrease). Medicaid non-institutional LTSS expenditures increased 10.2 percent, from $50.7 billion in FY 2008 to $55.9 billion in. These services included: Medicaid for Long-Term Services and Supports 7

10 Waivers authorized under Section 1915(c) of the Social Security Act ($35.1 billion, a 12.7 percent increase) Personal care ($13.8 billion, a 3.7 percent increase) Home health ($4.9 billion, a 6.6 percent increase) HCBS authorized under Section 1115 or Section 1915(a) of the Social Security Act ($1.4 billion, a 28.2 percent increase) PACE ($687 million, a 13.8 percent increase) Self-directed personal assistance services authorized under Section 1915(j) of the Social Security Act ($55 million, an 88.5 percent increase) 13 Rehabilitative services ( data unavailable) Private duty nursing ( data unavailable) State plan HCBS authorized under Section 1915(i) of the Social Security Act (FY 2009 data unavailable). VARIATION BY POPULATION SERVED State systems for people with developmental disabilities rely on Medicaid noninstitutional LTSS more than state systems serving older adults and people with physical disabilities. 14 Non-institutional services comprised 36 percent of LTSS expenditures targeting older adults and people with physical disabilities. For this population group, only six states spent more than 50 percent of LTSS dollars on noninstitutional services. The non-institutional portion of LTSS expenditures has doubled from 17 percent in FY 1995, the first year for which data by the population served were available. Most of the increase occurred after FY 2002 (See Figure 4 on the following page). 13 This figure includes self-directed service programs that started as Section 1115 waivers before Congress passed Section 1915(j). 14 Population categories are based on programs (e.g., the State Plan personal care service, a 1915(c) waiver), and are not based on individual age or diagnosis. Some programs primarily serve older adults and people with physical disabilities, but may also serve people with cognitive impairments and/or people with serious mental illness. In addition, some individuals have multiple conditions and could be served in multiple types of programs. Medicaid for Long-Term Services and Supports 8

11 Figure 4: Medicaid LTSS for Older Adults and People with Physical Disabilities, in Billions, For programs targeting persons with developmental disabilities, only six states spent less than 50 percent of LTSS dollars on non-institutional services. Noninstitutional spending comprised 66 percent of Medicaid LTSS expenditures for this population. One reason for this difference is that programs for people with developmental disabilities are more likely to provide support 24-hours a day. As illustrated in Figure 5 on the following page, the non-institutional portion of LTSS expenditures has doubled from 30 percent in FY Medicaid for Long-Term Services and Supports 9

12 Figure 5: Medicaid LTSS for People with Developmental Disabilities, in Billions, USE OF PRIOR PERIOD ADJUSTMENTS The figures and tables in this report include prior period adjustments to the CMS 64 reports for the following Medicaid program authorities and fiscal years: Waivers authorized under Section 1915(c) of the Social Security Act since FY 1995 Personal care since FY 2002 (starting in FY 2001 for California) Nursing home, ICF/MR, inpatient hospital, mental health facilities, and disproportionate share hospital payments (both inpatient and mental health) since FY 2002 PACE since FY 2004 All other services starting in. We started obtaining adjustment data for 1915(c) waivers and personal care expenditures to correct historical underreporting in California that occurred largely because state agencies other than the state s Medicaid agency administered these benefits. We included adjustments for several types of facility services and for PACE after we learned that several states report a significant portion of these expenditures Medicaid for Long-Term Services and Supports 10

13 through prior period adjustments. We included adjustments for all services when CMS provided access to all prior period adjustment data. Prior period adjustments typically have increased national Medicaid expenditures. For a few states, especially California and New York, the effect of prior period adjustments on state Medicaid LTSS expenditures has often been significant. States submit most adjustments within two years of the initial CMS quarterly report. Thus, it is reasonable to assume that prior period adjustments submitted in FY 2011 and subsequent years will moderately increase Medicaid LTSS expenditures data in this report, with a greater increase for FY 2010 than for. CAVEATS Several caveats apply to this report, with different stipulations for each data source. Three caveats apply to the CMS 64 reports, which provide most of the data. First, these reports represent state claims to the Federal government for expenditures that states believe are eligible for Federal matching funds. As a result of its audit process, CMS may disallow some of these claims. Disallowances are not reported by type of service and therefore cannot be used to adjust previously-reported Medicaid spending data by type of service. Second, CMS 64 data are by date of payment. s in state Medicaid spending may reflect state payment policies as well as real changes in service utilization. For example, a state can push 13 months of nursing home spending into a later fiscal year by delaying one month of payments to nursing home providers from September 30 to October 1. This leaves only 11 months of nursing home payments in the earlier year. Finally, the CMS 64 classifies expenditures into several service categories. We present data for those services that are primarily associated with LTSS. Many states offer service categories that can include both acute care and LTSS, such as targeted case management. Several states, such as Georgia, have large case management programs that are specifically focused on people receiving LTSS. Different caveats apply to state-reported managed care data. States submitted two types of data: the amount paid by managed care organizations for LTSS (i.e., encounter data) and capitation payments by the state to the managed care organization for the additional cost of serving LTSS participants (i.e., rate-setting data). States generally do Medicaid for Long-Term Services and Supports 11

14 not audit encounter data, which can vary in quality. 15 Rate setting data are estimates of what the state would have paid if the target population remained in fee-for-service, which does not directly represent the cost of services to participants. In addition, states often use financing mechanisms such as payment withholding, incentive payments, performance payments, risk-sharing, and reinsurance. It is difficult to calculate the LTSS portion of payments based on these funding mechanisms because LTSS are only part of the managed care service package in most states. ACKNOWLEDGEMENTS We would like to thank Melissa Hulbert, Christopher Kessler, and Jean Accius in the CMS Center for Medicaid, CHIP, and Survey & Certification for their assistance in making these data available and for assisting us in their interpretation. 15 Levinson, D. Medicaid Managed Care Encounter Data: Collection and Use. U.S. Department of Health and Human Services, Office of Inspector General: May 2009, available at (Accessed on May 13, 2010). Medicaid for Long-Term Services and Supports 12

15 APPENDIX A: NATIONAL DATA TABLES

16 Table 1 Medicaid for Long-Term Services and Supports: (in thousands of dollars) Service Type FY 2005 FY 2006 FY 2007 FY 2008 FY 2010 Nursing homes $47,481,182 $47,698, $47,090, $50,012, $51,264, $49,804, % ICF/MR $12,483,292 $13,034, $12,436, $12,899, $13,250, $12,871, % Mental health facilities $4,345,995 $3,489, $3,672, $3,433, $3,345, $3,407, % Mental health facilities DSH $3,369,710 $3,254, $3,207, $3,343, $3,327, $2,614, % Total institutional $67,680,180 $67,476, $66,407, $69,688, $71,187, $68,696, % Personal care $9,453,781 $10,064, $11,275, $13,274, $13,766, $12,466, % Home health $3,555,813 $3,743, $3,961, $4,567, $4,869, $4,756, % 1915(c) waivers $22,971,848 $25,722, $28,226, $31,134, $35,081, $35,914, % HCBS & 1915(a) $0 $33, $42, $1,120, $1,436, $ n/a PACE $480,539 $453, $492, $604, $687, $775, % Rehabilitative services $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $2,507, n/a Private duty nursing $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $632, n/a HCBS (i) $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $8, n/a HCBS (j) $60,735 $68, $60, $27, $54, $55, % Personal care (j) $3,464 $4, $4, $1, $ $20, % Total non-institutional $36,526,180 $40,090, $44,062, $50,730, $55,896, $57,137, % Total LTSS $104,206,360 $107,566, $110,470, $120,418, $127,083, $125,834, % Total Medicaid $304,625,344 $302,501, $317,759, $336,841, $368,330, $380,322, % Data for , and 2010 do not include managed care data for nursing homes, ICF/MR, personal care, home health, 1915(c) waivers, and HCBS & 1915(a). ACRG - annual compound rate of growth PACE - Program of All-inclusive Care for the Elderly Sources: CMS 64 data, Division of Financial Operations Kasten J, Eiken S, Burwell B. Medicaid Managed Long -Term Services and Supports. Thomson Reuters: April 6, 2011 (for 2008 and 2009 only). ACRG

17 Nursing Homes Table A State FY 2005 FY FY FY FY 2010 Per State Resident New York $6,936,890,672 $6,950,722, $6,771,786, $7,305,185, $7,675,245, $6,851,543, $ Connecticut $1,050,418,002 $1,225,260, $1,232,775, $1,241,791, $1,239,838, $1,254,179, $ Washington DC $176,347,294 $173,483, $173,010, $181,248, $197,295, $204,874, $ Pennsylvania $4,372,891,645 $3,938,590, $3,798,184, $3,935,891, $3,605,567, $3,504,082, $ Rhode Island $294,427,160 $298,125, $299,966, $297,862, $293,189, $304,786, $ North Dakota $158,222,671 $166,175, $166,949, $167,127, $172,397, $188,846, $ Massachusetts $1,684,532,818 $1,666,269, $1,544,377, $1,600,698, $1,746,032, $1,684,310, $ West Virginia $392,226,362 $401,576, $420,956, $442,303, $459,245, $480,001, $ Mississippi $612,337,281 $648,135, $693,389, $712,853, $727,351, $747,895, $ New Hampshire $348,149,110 $291,346, $295,239, $303,216, $314,619, $309,381, $ New Jersey $1,928,693,361 $1,825,194, $1,814,945, $1,911,287, $1,984,403, $1,880,574, $ Ohio $2,736,270,383 $2,662,845, $2,661,023, $2,556,868, $2,564,652, $2,714,648, $ Delaware $154,856,126 $159,962, $162,657, $176,289, $185,844, $185,834, $ Wisconsin $954,567,674 $964,489, $918,983, $800,019, $1,171,162, $917,550, $ Alabama $838,003,192 $837,819, $869,818, $835,392, $938,114, $875,233, $ Arkansas $491,751,667 $521,803, $541,166, $562,506, $572,748, $615,035, $ Kentucky $722,057,446 $734,574, $756,414, $806,508, $827,805, $836,559, $ Maine $200,084,164 $235,263, $237,469, $253,332, $252,448, $257,667, $ Vermont $103,761,799 $101,406, $110,756, $115,353, $116,585, $115,111, $ Maryland $891,097,477 $937,507, $961,848, $1,008,231, $1,061,516, $1,060,584, $ Indiana $1,285,442,850 $981,242, $1,009,581, $1,209,358, $1,195,097, $1,184,292, $ Nebraska $352,507,058 $346,617, $340,800, $332,017, $317,785, $317,931, $ South Dakota $127,472,842 $133,199, $135,932, $138,111, $142,270, $144,038, $ Alaska $119,071,602 $123,440, $126,076, $74,009, $118,855, $117,642, $ Louisiana $652,850,543 $638,071, $692,248, $720,733, $745,621, $776,006, $ Minnesota $859,096,238 $850,674, $834,645, $859,873, $871,036, $811,877, $ Montana $138,397,465 $146,689, $148,616, $152,760, $158,222, $156,002, $ Michigan $1,609,435,863 $1,447,440, $1,482,976, $1,487,455, $1,546,864, $1,673,410, $ Iowa $428,853,379 $443,873, $449,355, $469,324, $466,661, $494,186, $ Tennessee $906,528,315 $1,055,146, $1,063,716, $1,040,896, $975,022, $623,733, $ Missouri $803,678,068 $761,167, $759,452, $848,741, $869,379, $908,286, $ Oklahoma $450,918,625 $454,948, $505,734, $528,366, $529,503, $508,382, $ North Carolina $1,144,670,259 $1,113,024, $1,118,638, $1,114,886, $1,291,788, $1,222,817, $ Wyoming $63,148,012 $63,639, $67,851, $69,720, $72,830, $74,284, $ Kansas $336,089,245 $323,478, $359,317, $360,896, $373,226, $357,760, $ Florida $2,228,586,334 $2,395,913, $2,341,742, $2,414,746, $2,423,463, $2,785,587, $ Illinois $1,397,496,709 $1,471,086, $1,414,774, $1,461,329, $1,616,409, $1,535,935, $ California $3,099,880,820 $3,857,308, $3,806,536, $4,310,776, $4,429,935, $4,122,337, $ South Carolina $506,621,835 $463,073, $489,665, $503,057, $513,252, $570,714, $ Colorado $451,175,002 $471,276, $495,541, $499,645, $548,943, $573,428, $ Idaho $129,943,097 $136,523, $145,765, $156,283, $157,450, $125,051, $ Georgia $1,390,399,452 $1,195,813, $671,181, $1,311,924, $993,479, $1,308,979, $ Virginia $683,670,465 $707,898, $723,020, $744,750, $768,980, $802,896, $ Washington $583,299,081 $555,539, $592,401, $575,916, $581,051, $578,606, $ Texas $1,715,175,351 $1,833,379, $1,881,397, $1,947,506, $2,151,980, $2,307,456, $ Hawaii $196,096,956 $191,682, $205,174, $221,880, $104,681, $2,182, $ Oregon $255,636,038 $280,370, $291,260, $319,644, $304,402, $362,428, $ Arizona $24,090,705 $25,631, $12,995, $424,022, $447,166, $34,372, $ New Mexico $198,830,886 $195,240, $174,595, $173,981, $130,763, $5,246, $ Nevada $152,099,321 $149,825, $155,014, $163,576, $162,315, $171,012, $ Utah $142,433,539 $144,679, $163,109, $162,277, $149,561, $158,455, $53.78 United States $47,481,182,259 $47,698,450, $47,090,843, $50,012,438, $51,264,073, $49,804,050, $ Alaska's reported 2008 NF expenditures decreased significantly from The $42 million decrease is similar to the increase in reported ICF/MR spending, so it is possible NF expenditures were reported under ICF/MR. Hawaii's 2009 and 2010 data do not include expenditures for a managed care program that provides long-term services and supports. Data for and for 2010 do not include managed care data from Arizona, California, Florida, Massachusetts, Minnesota, New Mexico, New York, Texas, Vermont, and Wisconsin.

18 ICF/MR Table B State FY 2005 FY FY FY FY 2010 Per State Resident New York $2,828,388,965 $3,388,581, $3,057,176, $3,155,327, $3,192,913, $3,373,068, $ Connecticut $219,690,073 $288,306, $240,164, $236,997, $524,279, $292,218, $ Washington DC $79,196,025 $79,031, $85,050, $82,579, $73,766, $69,360, $ North Dakota $64,514,596 $62,435, $61,682, $68,042, $77,817, $90,198, $ Louisiana $425,679,479 $426,058, $442,050, $480,841, $468,057, $472,346, $ Iowa $249,507,427 $265,175, $276,651, $289,805, $305,883, $286,660, $ Mississippi $209,110,070 $253,584, $255,287, $285,877, $277,194, $269,536, $ New Jersey $527,683,406 $643,693, $628,420, $633,120, $664,713, $619,411, $ Ohio $1,056,446,387 $779,263, $697,689, $691,993, $738,206, $763,029, $ North Carolina $453,456,221 $454,126, $466,771, $499,305, $517,293, $491,450, $ Arkansas $140,908,587 $134,352, $146,959, $147,860, $144,399, $158,996, $ Wisconsin $194,049,379 $171,019, $131,157, $38,708, $280,691, $145,075, $ Maine $55,344,499 $70,527, $71,691, $64,101, $65,185, $60,512, $ Pennsylvania $590,964,344 $570,626, $584,411, $584,295, $620,380, $598,966, $ Indiana $315,325,423 $341,398, $318,569, $301,047, $312,589, $313,996, $ Illinois $714,660,262 $724,043, $696,182, $743,274, $611,548, $636,142, $ Tennessee $285,121,731 $267,447, $243,129, $241,018, $267,505, $225,405, $ Texas $871,155,434 $888,932, $906,152, $959,803, $1,018,428, $974,081, $ Nebraska $59,443,762 $60,368, $66,940, $68,217, $66,975, $34,312, $ Virginia $245,354,875 $249,477, $231,039, $279,463, $288,251, $270,359, $ South Carolina $161,433,481 $161,278, $157,179, $154,255, $166,524, $140,569, $ Idaho $57,413,151 $59,546, $59,701, $62,009, $55,032, $66,258, $ West Virginia $55,415,967 $56,047, $57,353, $60,128, $63,958, $62,594, $ Oklahoma $121,538,311 $125,060, $127,302, $126,917, $126,206, $123,591, $ Minnesota $171,455,673 $171,341, $175,376, $178,358, $173,914, $169,111, $ Wyoming $18,335,225 $18,287, $20,006, $18,312, $17,520, $18,503, $ Delaware $25,821,497 $22,750, $26,647, $29,834, $27,903, $30,733, $ South Dakota $21,296,554 $20,785, $20,148, $22,366, $23,336, $24,523, $ Missouri $256,680,290 $241,855, $105,836, $129,143, $152,896, $133,887, $ Utah $57,513,532 $60,702, $58,133, $72,082, $67,815, $57,404, $ Kansas $66,957,183 $64,980, $64,630, $63,194, $66,100, $61,911, $ Washington $124,981,179 $125,497, $114,863, $150,372, $155,556, $141,460, $ Kentucky $107,749,062 $128,758, $150,345, $110,812, $100,520, $145,522, $ California $787,068,706 $816,635, $814,012, $880,121, $819,930, $560,645, $ Florida $301,190,366 $314,472, $319,288, $338,268, $328,449, $333,717, $ Massachusetts $213,106,263 $165,680, $206,611, $234,756, $90,645, $417,064, $ Montana $12,350,308 $12,744, $10,631, $13,375, $12,147, $12,659, $ New Mexico $20,568,181 $21,712, $21,263, $23,171, $24,014, $24,694, $ Rhode Island $7,067,988 $7,813, $7,810, $8,737, $11,424, $11,462, $ Alabama $27,248,061 $25,886, $31,522, $36,179, $37,940, $34,859, $ Maryland $63,962,424 $65,576, $68,465, $65,317, $44,205, $1, $ Hawaii $8,597,309 $7,642, $8,682, $9,027, $9,903, $9,014, $ Georgia $99,663,677 $114,649, $105,885, $100,501, $73,794, $91,956, $ Nevada $26,472,598 $26,727, $21,390, $18,993, $16,426, $18,473, $ Colorado $58,742,900 $47,752, $22,646, $22,289, $23,440, $28,485, $ Arizona $0 $0 0.0 $0 0.0 $28,242, $28,383, $ $ New Hampshire $2,348,269 $2,483, $2,521, $3,005, $3,252, $3,106, $ Alaska $0 $0 0.0 $168, $45,669, $1,454, $1,644, $ Vermont $944,808 $ $0 0.0 $1,183, $1,226, $ $ Oregon $0 $0 0.0 $22,407, $13,946, $6,763, $2,192, $ Michigan $21,368,027 $28,989, $28,824, $27,348, $3,410, $ $0.34 United States $12,483,291,935 $13,034,110, $12,436,838, $12,899,606, $13,250,185, $12,871,180, $42.92 Alaska's reported 2008 ICF/MR expenditures are much greater than actual spending. Alaska has no ICF/MR, but may pay for people needing out-of-state ICF/MR. Previously reported expenditures were less than $200,000. Data for and for 2010 do not include managed care data from Arizona, California, and Vermont.

19 Mental Health Facilities Table C State FY 2005 FY FY FY FY 2010 Per State Resident Wyoming $14,934,037 $18,815, $22,196, $27,509, $30,153, $21,827, $ Arkansas $124,727,597 $139,039, $136,404, $135,044, $142,810, $149,037, $ Maine $29,675,138 $47,256, $53,824, $57,890, $52,510, $49,349, $ Ohio $389,902,871 $397,282, $401,717, $494,838, $442,509, $469,385, $ Maryland $160,866,528 $168,112, $188,626, $184,548, $192,259, $93,907, $ Nebraska $44,805,057 $44,737, $41,497, $41,641, $58,259, $34,255, $ West Virginia $36,105,561 $38,920, $40,012, $44,734, $49,543, $70,808, $ Oklahoma $58,726,151 $61,812, $79,140, $94,674, $99,913, $80,726, $ New York $434,586,784 $497,984, $543,649, $474,364, $504,271, $523,401, $ Alaska $11,605,276 $21,552, $19,992, $16,055, $16,628, $16,778, $ Massachusetts $55,596,900 $156,190, $165,658, $44,623, $146,865, $145,326, $ Mississippi $40,997,855 $50,718, $52,872, $57,546, $61,561, $66,796, $ Virginia $294,241,247 $393,266, $494,226, $308,661, $144,899, $123,411, $ North Dakota $2,864,051 $2,986, $8,551, $11,592, $11,850, $10,737, $ New Jersey $136,717,139 $145,555, $144,494, $137,753, $155,570, $144,876, $ Washington DC $15,307,481 $13,961, $10,292, $7,581, $9,945, $16,868, $ Montana $18,290,650 $20,524, $17,311, $15,186, $16,075, $15,429, $ Nevada $38,176,678 $42,085, $47,887, $60,564, $41,944, $38,678, $ Connecticut $10,495,916 $28,267, $49,358, $46,601, $52,752, $42,115, $ Alabama $46,441,208 $48,280, $53,738, $59,902, $60,947, $60,482, $ Iowa $31,979,230 $32,975, $22,386, $44,374, $38,725, $36,656, $ South Carolina $35,271,613 $39,954, $36,913, $38,790, $56,661, $52,852, $ Kentucky $49,105,404 $42,358, $43,476, $46,383, $50,745, $56,073, $ Minnesota $47,345,252 $54,728, $59,303, $66,026, $53,639, $61,816, $ Idaho $14,457,617 $15,486, $15,500, $16,458, $14,643, $10,181, $ Indiana $60,665,667 $67,842, $66,798, $62,477, $59,812, $59,685, $ North Carolina $43,482,163 $50,153, $69,506, $70,313, $86,748, $65,681, $ Illinois $57,784,487 $77,950, $95,111, $99,450, $99,542, $112,671, $ Missouri $25,864,547 $27,373, $37,595, $42,516, $44,112, $43,102, $ California $1,567,457,227 $293,244, $266,168, $265,643, $257,524, $327,553, $ Pennsylvania $149,373,730 $154,417, $108,345, $74,026, $75,023, $73,822, $ Utah $13,045,038 $12,586, $13,966, $15,283, $16,337, $16,505, $ Kansas $11,719,669 $8,467, $7,576, $6,996, $15,255, $55,415, $ Rhode Island $9,113,235 $9,759, $9,842, $8,028, $5,342, $5,272, $ Wisconsin $33,802,313 $30,286, $27,391, $25,858, $28,526, $21,655, $ South Dakota $3,095,557 $3,523, $3,810, $4,020, $3,649, $29,006, $ Louisiana $12,014,050 $52,025, $15,505, $17,664, $19,135, $17,438, $ Washington $28,200,452 $29,666, $31,692, $55,225, $26,804, $26,741, $ New Hampshire $3,175,112 $3,321, $3,169, $3,233, $4,600, $4,117, $ New Mexico $10,930,114 -$177, $15,947, $4,018, $5,029, $3,151, $ Michigan $24,671,557 $24,940, $24,611, $20,099, $21,493, $17,301, $ Georgia $33,048,221 $22,736, $23,508, $28,008, $19,325, $25,897, $ Delaware $37,423,216 $34,274, $37,045, $20,770, $1,181, $1,269, $ Texas $26,112,088 $23,324, $19,168, $24,910, $26,955, $24,161, $ Florida $4,402,683 $6,436, $8,176, $9,437, $14,461, $58,548, $ Colorado $4,130,093 $4,055, $4,170, $3,386, $3,898, $4,304, $ Oregon $40,721,995 $28,089, $17,442, $17,172, $2,759, $7,115, $ Arizona $1,426,485 $1,750, $2,191, $1,575, $1,439, $1,658, $ Tennessee $926,334 $311, $14,621, $19,598, $1,214, $13,385, $ Hawaii $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $ Vermont $185,997 $ $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0.00 United States $4,345,995,271 $3,489,214, $3,672,395, $3,433,066, $3,345,864, $3,407,244, $10.84 Data do not include services provided through managed care organizations.

20 Mental Health Facilities - DSH Table D State FY 2005 FY FY FY FY 2010 Per State Resident New Jersey $456,981,208 $483,287, $458,085, $597,177, $506,221, $357,370, $ Maine $50,296,700 $51,887, $42,364, $48,187, $51,447, $102,269, $ Missouri $207,234,618 $204,780, $205,201, $203,173, $198,763, $192,572, $ New York $605,000,000 $605,000, $605,000, $605,000, $605,000, $145,500, $ Connecticut $97,269,727 $97,269, $97,269, $97,269, $104,088, $105,573, $ Pennsylvania $324,025,553 $316,903, $320,748, $322,438, $328,721, $238,544, $ New Hampshire $72,097,274 $37,153, $41,321, $39,479, $34,392, $35,283, $ Louisiana $112,845,178 $73,284, $109,724, $94,989, $110,121, $108,929, $ Alaska $7,044,770 $8,171, $9,479, $12,064, $13,357, $13,503, $ Washington $115,008,432 $115,008, $114,733, $110,763, $120,336, $125,845, $ North Carolina $143,758,082 $144,425, $142,117, $143,152, $149,908, $154,424, $ Indiana $95,405,732 $152,096, $95,241, $107,770, $96,145, $89,044, $ Michigan $133,089,577 $141,909, $141,909, $141,774, $141,909, $93,922, $ Texas $286,040,764 $287,066, $286,016, $287,540, $292,513, $292,513, $ South Carolina $68,814,096 $52,825, $52,404, $53,835, $52,761, $48,582, $ West Virginia $23,291,631 $20,377, $18,911, $18,684, $18,873, $18,887, $ Maryland $47,402,123 $47,402, $47,402, $47,402, $50,547, $51,993, $ Kentucky $37,430,614 $37,443, $37,435, $37,343, $37,443, $37,443, $ Illinois $89,046,247 $89,312, $89,491, $67,162, $111,393, $89,423, $ Ohio $93,432,758 $93,432, $93,432, $93,432, $93,432, $93,432, $ Kansas $21,016,040 $21,224, $15,960, $26,895, $22,749, $23,292, $ Delaware $3,578,474 -$190, $9,217, $5,628, $5,853, $6,294, $ Florida $103,563,144 $105,439, $103,809, $107,335, $112,437, $122,087, $ Arizona $28,474,900 $28,474, $28,474, $28,474, $28,474, $28,474, $ Oregon $14,190,169 $16,983, $19,861, $19,975, $14,981, $19,952, $ Washington DC $2,446,012 $2,159, $3,454, $2,362, $2,093, $2,047, $ North Dakota $988,478 $988, $988, $988, $987, $988, $ Rhode Island $2,390,330 $2,397, $2,397, $2,397, $1,578, $ $ Nebraska $1,707,322 $298, $1,811, $1,863, $1,762, $ $ South Dakota $751,299 $751, $558, $751, $751, $648, $ Virginia $4,675,525 $4,907, $5,235, $6,648, $7,129, $6,284, $ Oklahoma $3,138,655 $3,273, $3,273, $3,273, $3,273, $3,273, $ Alabama $3,301,620 $3,301, $825, $2,751, $3,301, $3,301, $ Wisconsin $6,019,295 $2,312, $1,649, $4,237, $3,945, $ $ New Mexico $0 $254, $254, $254, $254, $254, $ Tennessee $0 $ $352, $ $349, $ $ Utah $934,553 $934, $934, $934, $89, $934, $ Minnesota $696,816 $920, $687, $82, $82, $381, $ Arkansas $819,350 $819, $ $0 0.0 $0 0.0 $819, $ California $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $ Colorado $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $ Georgia $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $ Hawaii $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $ Iowa $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $ Idaho $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $ Massachusetts $105,503,250 $ $0 0.0 $0 0.0 $0 0.0 $0 0.0 $ Mississippi $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $ Montana $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $ Nevada $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $ Vermont $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $ Wyoming $0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0 0.0 $0.00 United States $3,369,710,316 $3,254,289, $3,207,337, $3,343,497, $3,327,473, $2,614,095, $10.78

21 Total Institutional Long-Term Services and Supports Table E State FY 2005 FY FY FY FY 2010 Per State Resident New York $10,804,866,421 $11,442,288, $10,977,612, $11,539,876, $11,977,430, $10,893,514, $ Connecticut $1,377,873,718 $1,639,104, $1,619,568, $1,622,660, $1,920,958, $1,694,087, $ Washington DC $273,296,812 $268,635, $271,808, $273,771, $283,101, $293,150, $ North Dakota $226,589,796 $232,585, $238,171, $247,751, $263,052, $290,770, $ New Jersey $3,050,075,114 $3,097,731, $3,045,946, $3,279,338, $3,310,908, $3,002,232, $ Pennsylvania $5,437,255,272 $4,980,537, $4,811,689, $4,916,651, $4,629,693, $4,415,415, $ Mississippi $862,445,206 $952,439, $1,001,548, $1,056,278, $1,066,107, $1,084,228, $ Ohio $4,276,052,399 $3,932,824, $3,853,863, $3,837,133, $3,838,801, $4,040,496, $ West Virginia $507,039,521 $516,921, $537,234, $565,851, $591,620, $632,292, $ Maine $335,400,501 $404,935, $405,349, $423,511, $421,591, $469,799, $ Massachusetts $2,058,739,231 $1,988,140, $1,916,647, $1,880,079, $1,983,543, $2,246,701, $ Louisiana $1,203,389,250 $1,189,439, $1,259,529, $1,314,229, $1,342,935, $1,374,722, $ Arkansas $758,207,201 $796,014, $824,530, $845,411, $859,959, $923,888, $ Rhode Island $312,998,713 $318,095, $320,017, $317,026, $311,535, $321,521, $ New Hampshire $425,769,765 $334,304, $342,253, $348,934, $356,864, $351,888, $ Iowa $710,340,036 $742,024, $748,393, $803,504, $811,270, $817,504, $ Wisconsin $1,188,438,661 $1,168,108, $1,079,181, $868,823, $1,484,325, $1,084,281, $ Indiana $1,756,839,672 $1,542,580, $1,490,190, $1,680,654, $1,663,643, $1,647,018, $ Delaware $221,679,313 $216,797, $235,567, $232,522, $220,782, $224,131, $ Nebraska $458,463,199 $452,022, $451,050, $443,739, $444,783, $386,499, $ Maryland $1,163,328,552 $1,218,598, $1,266,342, $1,305,499, $1,348,529, $1,206,486, $ Kentucky $916,342,526 $943,134, $987,670, $1,001,049, $1,016,514, $1,075,598, $ Wyoming $96,417,274 $100,742, $110,054, $115,542, $120,505, $114,614, $ Alabama $914,994,081 $915,288, $955,904, $934,225, $1,040,304, $973,876, $ North Carolina $1,785,366,725 $1,761,729, $1,797,034, $1,827,658, $2,045,739, $1,934,373, $ Alaska $137,721,648 $153,164, $155,716, $147,798, $150,296, $149,569, $ Missouri $1,293,457,523 $1,235,178, $1,108,085, $1,223,573, $1,265,150, $1,277,849, $ South Dakota $152,616,252 $158,259, $160,450, $165,249, $170,008, $198,216, $ Minnesota $1,078,593,979 $1,077,664, $1,070,013, $1,104,341, $1,098,672, $1,043,185, $ Oklahoma $634,321,742 $645,095, $715,451, $753,231, $758,897, $715,974, $ Tennessee $1,192,576,380 $1,322,905, $1,321,114, $1,301,513, $1,244,091, $862,523, $ Montana $169,038,423 $179,958, $176,559, $181,322, $186,445, $184,091, $ Vermont $104,892,604 $101,406, $110,756, $116,537, $117,811, $115,111, $ Illinois $2,258,987,705 $2,362,392, $2,295,560, $2,371,216, $2,438,894, $2,374,173, $ South Carolina $772,141,025 $717,131, $736,163, $749,939, $789,200, $812,719, $ Michigan $1,788,565,024 $1,643,279, $1,678,321, $1,676,677, $1,713,676, $1,784,633, $ Kansas $435,782,137 $418,152, $447,484, $457,982, $477,333, $498,379, $ Florida $2,637,742,527 $2,822,261, $2,773,017, $2,869,787, $2,878,811, $3,299,940, $ Virginia $1,227,942,112 $1,355,550, $1,453,521, $1,339,524, $1,209,261, $1,202,951, $ California $5,454,406,753 $4,967,187, $4,886,717, $5,456,541, $5,507,390, $5,010,537, $ Idaho $201,813,865 $211,555, $220,967, $234,751, $227,126, $201,491, $ Texas $2,898,483,637 $3,032,702, $3,092,734, $3,219,761, $3,489,877, $3,598,212, $ Washington $851,489,144 $825,711, $853,690, $892,277, $883,749, $872,653, $ Colorado $514,047,995 $523,084, $522,358, $525,320, $576,282, $606,219, $ Georgia $1,523,111,350 $1,333,199, $800,575, $1,440,434, $1,086,600, $1,426,833, $ Hawaii $204,694,265 $199,325, $213,857, $230,907, $114,585, $11,197, $ Oregon $310,548,202 $325,442, $350,971, $370,739, $328,907, $391,689, $ Utah $213,926,662 $218,902, $236,143, $250,577, $233,804, $233,300, $ Nevada $216,748,597 $218,638, $224,293, $243,134, $220,686, $228,164, $ New Mexico $230,329,181 $217,030, $212,060, $201,426, $160,062, $33,347, $ Arizona $53,992,090 $55,857, $43,661, $482,315, $505,464, $64,506, $76.73 United States $67,680,179,781 $67,476,064, $66,407,414, $69,688,608, $71,187,596, $68,696,569, $ Hawaii's 2009 and 2010 data do not include expenditures for a managed care program that provides long-term services and supports. Nursing facility and ICF/MR data for and for 2010 do not include managed care data from from Arizona, California, Florida, Massachusetts, Minnesota, New Mexico, New York, Texas, Vermont, and Wisconsin. Data do not include mental health facility services provided through managed care organizations..