Long-Term Services and Supports (LTSS)

Image of an older adult talking to a care provider, overlayed with clip art of three hands touching.

LTSS encompass a wide range of services designed to help individuals live more independently by assisting with personal and health care needs, including activities of daily living. LTSS providers may coordinate care for Medicaid beneficiaries in their own home or community and provide medical or non-medical services.

In 2018, there were 12.2 million individuals dually eligible for Medicare and Medicaid, and forty-nine percent of these individuals receive long-term care services and supports (LTSS).¹^,² Dually eligible beneficiaries are more than twice as likely to use LTSS compared to other Medicaid beneficiaries, and more than five times as likely compared to other Medicare beneficiaries.³ Supporting older adults and people with disability to live in home or in community settings leads to better health and maximum independence.⁴ Many states are shifting service delivery to managed LTSS (MLTSS) to improve coordination of care for dually eligible beneficiaries. MLTSS refers to the delivery of LTSS through a capitated Medicaid managed care program. This shift allows states to expand home and community-based services, promote community inclusion, ensure quality, and improve efficiency.⁵ Resources for Integrated Care has created several brief documents for LTSS providers and health plans to help them navigate moving to managed care and develop strong long-term partnerships to deliver coordinated, person-centered, and cost-effective care.

Cultural Competence in Long-Term Services and Supports (LTSS)

Long-term services and supports (LTSS) are critically important care for the many dually eligible beneficiaries who need support with activities of daily living (ADLs).⁶ People of color experience worse access, quality, and outcomes in LTSS, such as higher rates of re-hospitalization when they receive home health care⁷ and lower quality of care in nursing homes.⁸

Nearly half of all individuals dually eligible for Medicare and Medicaid receive help with personal care, such as bathing and dressing, managing medications, and other long-term services and supports.⁹ Given the intimate nature of these services, cultural competence – the ability to work effectively in cross-cultural situations – is a key part of establishing trust and respect between direct care workers and their clients.

⁶ The Medicare Payment Advisory Committee (MedPAC) and the Medicaid and CHIP Payment and Access Commission (MACPAC) (January 2018). Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid. Retrieved from https://www.macpac.gov/wp-content/uploads/2020/07/Data-Book-Beneficiaries-Dually-Eligible-for-Medicare-and-Medicaid-January-2018.pdf.

⁷ Office of the Assistant Secretary for Planning and Evaluation. (2016). Report to Congress: Social Risk Factors and Performance under Medicare's Value Based Purchasing Programs. Retrieved from https://aspe.hhs.gov/system/files/pdf/253971/ASPESESRTCfull.pdf.

⁸ Campbell, L. J., Cai, X., Gao, S., & Li, Y. (2016). Racial/Ethnic Disparities in Nursing Home Quality of Life Deficiencies, 2001 to 2011. Gerontology and Geriatric Medicine, 2, 23337214166653561. https://journals.sagepub.com/doi/10.1177/****************.

⁹ Centers for Medicare and Medicaid Services (2019). Fact Sheet: People Dually Eligible for Medicare and Medicaid. Retrieved from https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf.
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Plan and Provider LTSS Partnerships
LTSS encompasses a broad range of services and supports that are critically important to many dually eligible beneficiaries who need help with activities of daily living (ADLs).¹⁰ States have broad program design options under multiple Medicaid managed care authorities. States set requirements through formal contracts approved by CMS prior to implementation. However, health plans and providers have some flexibility around how to implement some of the requirements.

LTSS providers include nursing facilities, personal care agencies, and other home and community-based service (HCBS) providers, as well as paid caregivers under participant-directed service options. These providers may have limited experience in working with health plans. Similarly, though health plans may be accustomed to contracting for institutional-based acute care services, they may not have as much experience with the LTSS that providers deliver, often in the community.

Resources for Integrated Care has created several brief documents to support the partnership between health plans and LTSS providers. These briefs outline:
- General considerations for health care organizations when contracting or entering into agreements with health plans or providers.
- Key issues that may be addressed and negotiated in the contract.
- Steps for transitioning to LTSS, training and credentialing considerations.
- Potential issues that may arise.
¹⁰ The Medicare Payment Advisory Committee (MedPAC) and the Medicaid and CHIP Payment and Access Commission (MACPAC). (2018). Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid. Retrieved from https://www.macpac.gov/wp-content/uploads/2020/07/Data-Book-Beneficiaries-Dually-Eligible-for-Medicare-and-Medicaid-January-2018.pdf.
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¹ Medicare-Medicaid Coordination Office. (2020). Medicare-Medicaid Dual Enrollment from 2006 through 2019. Available at: https://www.cms.gov/files/document/medicaremedicaiddualenrollmenteverenrolledtrendsdatabrief.pdf.

² Medicare-Medicaid Coordination Office. People Dually Eligible for Medicare and Medicaid – Fact Sheet. (2020). Available at: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf.

³ Congressional Budget Office. (2013). Dual-Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies. Available at: https://www.cbo.gov/sites/default/files/113th-congress-2013-2014/reports/44308dualeligibles2.pdf.

⁴ Centers for Medicare and Medicaid Services. LTSS Overview. Available at: https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/info/ltss-overview.

⁵ Center for Medicare and Medicaid Services (CMS). Managed Long Term Services and Supports. Available at: https://www.medicaid.gov/medicaid/managed-care/managed-long-term-services-and-supports/index.html.

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