Understanding Primary Diagnosis
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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 (2019)
Primary Diagnosis Category People Percent
Autism Spectrum Disorder 24,915 20.9%
Cerebral Palsy 4,401 3.7%
Epilepsy / Seizure Disorder 1,240 1.0%
Intellectual Disability – Mild 42,320 35.4%
Intellectual Disability – Moderate 11,260 9.4%
Intellectual Disability – Severe 5,450 4.6%
Intellectual Disability – Profound 5,737 4.8%
Intellectual Disability – Unspecified 4,221 3.5%
Other Developmental Disorders / Delays 139 0.1%
Other Neurological Impairments 4,351 3.6%
Unknown / Unidentified 3,508 2.9%
Total 119,583 100%

 

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 (2019)
Funding Category Payments
Fee-For-Service $7,856,952,137
Fully Integrated Duals Advantage (FIDA-IDD) $147,543,896
Total* $8,004,496,034

*Rounding Error

Fee-For-Service Medicaid by Service Category

Over eighty percent of Medicaid payments in 2019 were for OPWDD certified housing and day and employment services (see Table 6 and Figure 6). 

Sixty percent (60%) of Medicaid payments were for OPWDD certified housing, followed by twenty-two percent (22%) for day and employment services (see Table 6 and Figure 6).

A pie graph of the breakdown of medicaid fee-for-service payments

 

Table 6. Medicaid Fee-For-Service Payments by OPWDD Service Category (2019)
Service Category Payments
Care Coordination $466,011,149
Certified Residential 3 $4,707,627,505
Community Habilitation $519,726,039
Day and Employment 4 $1,747,077,574
Other Supports and Services $211,468,132
Respite $205,041,738
Total $7,856,952,137

 

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 (2019)*
Certified Residential Housing  
Developmental Centers (DCs)/Special Residential Units (SRUs) 220
Family Care Homes 1,621
Intermediate Care Facilities (ICF) 4,553
Specialty Hospital 59
Supervised IRA/CRs 30,530
Supportive Individualized Residential Alternatives (IRAs)/Community Residences (CRs) 2,276
Total (Unduplicated) 38,506

 

*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.