Services by Primary Diagnosis

Individuals with developmental disabilities may have multiple diagnoses. For example, an individual with a primary diagnosis of intellectual disability may also have a secondary diagnosis of epilepsy. This data solely captures the primary diagnosis.

The primary diagnosis is identified for individuals during the determination of eligibility for Medicaid services. While additional or co-occurring conditions may be identified, the primary diagnosis is required and can be accurately reported.

Individuals identified as having an “unknown/unidentified” primary diagnosis visited an Article 16 clinic to determine whether a developmental disability diagnosis was present.

Table 4. People Receiving OPWDD Medicaid Services by Primary Diagnosis (2021)
Primary Diagnosis Category People Percent
Autism Spectrum Disorder 29,942 24.2%
Cerebral Palsy 4,414 3.6%
Epilepsy / Seizure Disorder 1,336 1.1%
Intellectual Disability – Mild 41,734 33.7%
Intellectual Disability – Moderate 12,031 9.7%
Intellectual Disability – Profound 4,788 3.9%
Intellectual Disability – Severe 5,355 4.3%
Intellectual Disability – Unspecified 4,173 3.4%
Other Developmental Disorders / Delays 5,259 4.2%
Other Neurological Impairments 3,730 3.0%
Unknown / Unidentified 11,191 9.0%
Total 123,953  

 

Payments by Funding Category

Payments are made to providers for the delivery of OPWDD Medicaid services in two ways: (1) on a fee-for-service (FFS) basis; or (2) through a managed care arrangement.  Under a FFS model, a separate payment is made for each service delivered to a person.  For managed care, a set monthly fee, or capitation payment, is paid to an insurance company that then manages care and pays service providers. The Fully Integrated Duals Advantage (FIDA) demonstration program provides comprehensive medical, behavioral health and long-term supports and services to dually Medicare and Medicaid eligible individuals with intellectual and developmental disabilities (IDD) in a managed care service delivery model.

Table 5. Medicaid Payments by Funding Category (2021)
Funding Category Payments
Fee-For-Service Medicaid $7,793,740,215
Fully Integrated Duals Advantage (FIDA-IDD) $234,624,140
Total* $8,028,364,355

*Rounding Error

Fee-For-Service Medicaid by Service Category

About eighty percent of Medicaid payments in 2020 were for OPWDD certified housing and day and employment services (see Table 6 and Figure 6). 

Sixty percent (59%) of Medicaid payments were for OPWDD certified housing, followed by twenty-two percent (21%) for day and employment services (see Table 6).

Table 6. Medicaid Fee-For-Service Payments by OPWDD Service Category (2020)
Service Category Payments
Care Coordination $431,243,535
Certified Residential 3 $4,938,586,300
Community Habilitation $642,535,767
Day and Employment 4 $1,302,497,045
Other Supports and Services $272,064,137
Respite $206,813,432
Total $7,793,740,215

 

Services by Certified Housing Type

A majority of people (80%) in OPWDD certified housing lived in supervised IRAs/CRs (see Table 7).

Table 7. People Receiving OPWDD Medicaid Services by Certified Housing Type (2021)*
OPWDD Service Description Total Individuals
ICF/IDD- Community Model 3,849
ICF/IDD- Institutional Model 204
Residential Habilitation- CR/RA- Suprt 2,164
Residential Habilitation- CR/RA- Supvd 30,379
Residential Habilitation- Family Care 1,361
Specialty Hospital 60
Grand Total 37,528

 

*Counts include those receiving managed care. The unduplicated total count of people does not equal the sum of people by housing type as people can live in more than one housing type in a year.