Strengthening Medicaid Long-Term Services and Supports in an Evolving Policy Environment: A Toolkit for States

Anthony S, Traub A, Lewis S, Mann C
Publication Year: 2019
Patient Need Addressed: Long-term services and supports
Population Focus: Medicaid beneficiaries
Type of Literature: Grey

Long-term services and supports (LTSS) enable more than 12 million people to meet their personal care needs and live with dignity and independence in a variety of community and institutional settings. With Medicaid LTSS expenditures of more than $154 billion annually and the aging population projected to grow 18 % by 2020, the increasing demand for LTSS is putting more pressure on Medicaid at both the federal and state levels.

This toolkit, originally developed by CHCS and Manatt Health Strategies in 2017 and updated for 2019, provides a menu of LTSS reform strategies adopted by state innovators. It identifies concrete policy strategies, operational steps, and federal and state authorities that states have used to advance LTSS reforms, along with case studies and advice for other states embarking on a similar path.

Insights Results

Overview of resource

  • This is a toolkit for state policymakers (other stakeholders may find it useful as well) to help consider and improve the provision of long-term services and support, especially for high-need, high-cost patients. More specifically, this toolkit provides a targeted menu of existing state long term support service (LTSS) reform strategies that other states may replicate in whole or in part, or use to scale existing efforts. It is designed to assist states as they work to improve the delivery of LTSS by identifying concrete policy strategies, operational steps, and federal and state authorities that other states have used to advance their LTSS reforms. It also highlights opportunities and challenges that states faced in designing and implementing these reforms
    Methods of resource
  • To develop the toolkit, Manatt Health and CHCS conducted interviews with experts and implementers in innovator states to: 1) Inform descriptions of reform strategies; 2) Illuminate specific leading practices through case studies; and 3) Identify the considerations for when or how a strategy might be employed


    • There are 2 key areas in which states can implement strategies to deliver high-quality and high-value LTSS: 1) Rebalancing LTSS to increase the proportion of LTSS provided in community-based settings; and 2) Integrating LTSS with physical and behavioral health services
    • 3 specific strategies under “Rebalancing LTSS” include: 1) Develop LTSS system infrastructure to promote greater access to home- and community-based services (HCBS) (e.g., state investments in easy access to information for beneficiaries, sufficient and well-trained direct care workforce); 2) Invest in programs and services that help nursing facility residents return to and remain in their communities (e.g., state investments in housing transition services and affordable housing options); and 3) Expand access to HCBS for “Pre-Medicaid” individuals to prevent or delay nursing facility use. Although strides have been made in the right direction, challenges still exist and needs remain unmet under each strategy (e.g., state focus on providing limited HCBS to individuals who would not otherwise quality for Medicaid)
    • There are 4 specific strategies under “Integrating LTSS”: 1) Integrate Medicare-Medicaid benefits for dually eligible beneficiaries (e.g., expanding services to align them with Medicare managed care products for dually eligible patients to streamline service provision and tracking); 2) Integrate comprehensive care for Medicaid-only beneficiaries under capitated managed care (e.g., expanding managed care programs to include LTSS populations and associated services); 3) Enroll individuals with intellectual and developmental disabilities with managed care (e.g., transitioning LTSS benefits into existing managed care programs, creating care coordination entities as a pathway to managed care contracting arrangements, integrating all LTSS with medical, behavioral and social services into managed care); and 4) Integrate LTSS under provider-based initiatives (e.g., providing comprehensive medical and social services at the care delivery level through PACE, integrate LTSS within the health homes models for dually eligible beneficiaries)

    Key takeaways/implications

    • There is no one-size-fits-all approach to the challenge of LTSS system reform. A useful starting point for all states is to assess their current LTSS landscape and to reflect on challenges and successes and the reasons behind them. Based on that assessment, states can then set a strategic vision and course of action, selecting strategies from the toolkit as appropriate
    • Key considerations for states for each strategy include building and sustaining beneficiary engagement, investment in administrative capacity, investment in federal partnerships, cultivation of executive and legislative leadership and thinking long-term. States also need to consider and think creative about funding sources and new flexibilities to support reforms
    • Section 1115 waivers are an implementation mechanism for all 7 strategies along with other strategy-specific modes (e.g., state general funds, tax credits, Section 1945 health home state plan amendment)