States Seize Opportunities to Improve Medicaid Long-Term Services and Supports


Increasing State Interest in  Affordable Care Act Options that Impact LTSS Populations


A new study by the AARP Public Policy Institute finds that many states are moving to take advantage of new financial incentives to improve delivery of home- and community-based services (HCBS) to people who need long-term services and supports (LTSS).

Medicaid, the largest source of public funding for LTSS, gives states many options for providing HCBS. While states are not required to provide HCBS, all states provide at least some. The 2010 Affordable Care Act (ACA)  makes funding available to ramp up these efforts.

The report shows a flurry of ACA planning and implementation activities occurring at the state level, with many states applying for enhanced federal Medicaid matching rates and grants.

New LTSS provisions

  • State dual eligible initiatives aim to contain the growth of costs and improve care for people who have both Medicare and Medicaid coverage. These individuals typically are poorer and sicker than other Medicare beneficiaries and therefore use more health care services. Most states with these initiatives are turning to managed care. Thirty-four states either have or will launch new initiatives over the next two years.
  •  Health homes are providers or a health team that coordinates care across settings for people with chronic conditions and/or mental health conditions. Eleven states have received approval. Ten states are awaiting approval, and many more states are making plans.
  • Section 1915(i) HCBS State Plan Amendments allow states to provide LTSS in the community similar to existing Medicaid "waiver" programs, but with three major differences: 1) the individual does not need to meet an institutional level of care in order to qualify; 2) states may not cap enrollment; and 3) the program must operate statewide. Nine states have been approved. Two states are awaiting approval, and 11 are considering it.
  • Balancing Incentive Program is a temporary, noncompetitive grant program designed to encourage states to balance their Medicaid spending toward HCBS. To be eligible, a state must have spent less than 50 percent of its total Medicaid LTSS dollars on non-institutional services in FY 2009. Sixteen states have been approved, and three are considering it.
  • Community First Choice Option gives states the option to provide HCBS attendant services and supports where an individual could hire any qualified person, including family members. One state has been approved, and three are awaiting approval. Twelve states are considering it.


Want to know what your state is planning? See: At a Crossroads: Providing High Demand Long-Term Services and Supports in a Time of Fiscal Constraint, released this week by AARP's Public Policy Institute, Health Management Associates, and the National Association of States United for Aging and Disabilities. The study is based on a survey of 49 states and the District of Columbia in the fall of 2012. Since then, some states have submitted proposals and others have decided to forgo planning efforts. For up-to-date coverage, see NASUAD's State Medicaid Integration Tracker, which is updated monthly.

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About the Author: Wendy Fox-Grage is a senior strategic policy adviser for the AARP Public Policy Institute, where she works on long-term services and supports in the states. She has a Master of Science in gerontology and a master's in public administration.


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