SubHero Banner

Today is Edna’s 77th birthday. Her wish as she blows out her candles is that she can leave the nursing facility where she is currently staying and return home.*

Ten months ago, Edna tripped over a throw rug, breaking her right hip and arm in the fall. The injuries caused her to lose strength that she never regained, and she remains in a wheelchair, unable to dress or bathe herself without help.

Edna had no idea the day she tripped would be the last day she’d spend in her home.

Unfortunately, Edna’s situation is not unique. Millions of Americans live in institutional settings because they require long-term services and supports (LTSS).

And more than 12 million older adults and children living with a range of disabilities receive LTSS benefits.1 For fiscal year 2017, nearly $119 billion was spent on these much-needed long-term care services.2

Under Medicaid, the LTSS benefits that all states must provide typically include coverage for nursing facility care as well as home health services.3

States can decide whether to cover other types of LTSS, to what extent they will be covered and who will be eligible for them.

Optional LTSS services include the following:

  • Home and community-based services (HCBS), such as adult day health services
  • Personal care or attendant services
  • Home care and homemaker services
  • Home meal delivery
  • Home modifications
  • Respite care
  • Case management 4

Medicaid already covers six out of 10 seniors in nursing homes.5 With an aging population and a large group of people without the means to pay for long-term care needs, Medicaid will continue to be a primary payer of LTSS.6


Opportunities to maximize value

Health care experts, legislators, community advocates and Medicaid leaders agree on the need to maximize the value of each dollar spent on LTSS. How to achieve that value, however, can vary as much as the states providing them and the individuals receiving them.

Due to each state’s unique needs, the solutions for maximizing LTSS dollars will have to be driven at the state level.

States are able to identify and implement approaches to manage or reduce costs, and they can also design initiatives to improve the quality of life for Medicaid recipients.

Edna’s accident at home led to her placement in an institutional setting to receive LTSS. What if her state had implemented more initiatives that included home-safety assessments? Imagine instead of tripping on a throw rug, the care coordinator had Edna remove her throw rugs?

These types of preventive opportunities could be included in a more HCBS-focused Medicaid program. Some initiatives currently in place in some states include:

  • Promoting greater access to HCBS: States are modifying their LTSS infrastructure, access points to care and care-delivery networks to give greater access to HCBS.7 
  • Helping Medicaid recipients transition back into the community: Activities underway include allocating funds to obtain or build accessible, affordable housing, supporting the transition to community-based living instead of relying on continued institutionalized residency.8 Initiatives such as these would help Edna move back home in place of living in a nursing home for the rest of her life.
  • Extending assessments and benefits to “pre-Medicaid” recipients: Some states are expanding HCBS benefits to prevent or delay their need for longer-lasting, more expensive LTSS services.9
  • Rebalancing institutional-based and HCBS LTSS: By leveraging and coordinating services available through the community or in a community setting, states can extend the reach of their budget dollars. At the same time, they can support both the recipients and the communities in which they live.10
  • Transitioning to managed LTSS: Managed LTSS (MLTSS) is being implemented in managed care organizations across numerous states, with spending on MLTSS more than doubling between 2012 and 2015.11 Goals associated with MLTSS include: improvement in quality of care, outcomes, efficiency in delivery and management of services, and coordination of participant care as well as increased choice among consumers and access to HCBS.12
  • Standardizing the eligibility process: Functional assessments cover a range of categories including an individual’s ability to engage in “activities of daily living.” This assessment provides important information on the recipients’ current ability to take care of themselves in a home setting. It also offers insight into services and adaptions needed to help them function best in a HCBS setting. These screenings are a large part of Arkansas’ plan to save $835 million through 2021.
  • Increasing the direct services workforce: In 2017, there were 4.5 million direct care workers across all health care settings; 1.6 million of them were in a home-care setting.13 The need will continue to grow as the population ages. There is significant room for improvement in the salaries, benefits and protections provided for these critical-role workers.14
  • Educating the public: The public is generally unaware of the costs associated with long-term care, services and supports. This lack of knowledge contributes to poor financial planning, resulting in a lack of personal finances to pay for needed care and services later in life.15 Having a better financially prepared cohort using services may help limit Medicaid’s share of the growing LTSS price tag. One major initiative supported jointly by the federal and state governments is No Wrong Door. This is a system of organizations where people can get answers to their questions about long-term services and supports, including costs. The federal government also sponsors a website to increase awareness among the public about LTSS choices.

The potential is there

For states looking to curb LTSS costs while increasing quality of care and consumer options, many different strategies and tactics are available. They’ll take time to develop and implement, but creating a more effective, efficient and consumer-focused LTSS is worth it.


* This story is not based on actual events. Any similarity to actual persons, living or dead, is purely coincidental.



  1. Centers for Health Care Strategies, Inc. Strengthening Medicaid Long-Term Services and Supports in an Evolving Policy Environment: A Toolkit for States. Published December 2017. Accessed February 19, 2019.
  2. Kaiser Family Foundation. Distribution of Medicaid Spending by Service. Accessed February 24, 2019.
  3. Kaiser Family Foundation. Medicaid’s Role in Meeting Seniors’ Long-Term Services and Supports Needs. August 2, 2016. Accessed February 19, 2019.
  4. Ibid.
  5. Kaiser Family Foundation. Medicaid’s role in nursing home care. Published June 20, 2017. Accessed May 2, 2019.
  6. American Medical Association. Report 5 of the Medical Council on Medical Service (A-18) Financing of Long-Term Services and Supports (Reference Committee G). 2018. Accessed February 19, 2019.
  7. Center for Health Care Strategies and Manatt. Strengthening Medicaid Long-Term Services and Supports in an Evolving Policy Environment: A Toolkit for States. December 2017. Accessed February 19, 2019.
  8. Ibid.
  9. Ibid.
  10. Ibid.
  11. Centers for Medicare & Medicaid Services. The Growth of Managed Long-Term Services and Supports Programs: 2017 Update. January 29, 2019. Accessed February 19, 2019.
  12. Ibid.
  13. National Conference of State Legislatures. Aging Services. June 16, 2018. Accessed February 19, 2019.
  14. UnitedHealthcare Group. Professional Caregiving in the United States. August 2017. Accessed February 19, 2019.
  15. American Medical Association. Report 5 of the Medical Council on Medical Service (A-18) Financing of Long-Term Services and Supports (Reference Committee G). 2018. Accessed February 19, 2019.
Horizontal Rule

Related Solutions


Transitions to skilled nursing facilities

Make post-discharge transitions safer for patients who have recently suffered from an acute event.