LTSS stands for long-term services and supports, a broad category of help for people who need ongoing assistance with everyday activities due to chronic illness, disability, or aging. Unlike short-term medical care aimed at curing a specific problem, LTSS covers the sustained, often daily support that helps someone function and live as independently as possible. In 2023, roughly 9.7 million people received Medicaid-funded LTSS alone, making it one of the largest and most expensive segments of the U.S. healthcare system.
What LTSS Actually Covers
LTSS spans both medical and non-medical services. On the medical side, it includes skilled nursing care, physical therapy, and help managing medications or medical devices. On the non-medical side, it covers the kind of hands-on daily help that many people picture when they think of long-term care: assistance with bathing, dressing, eating, using the toilet, and moving around safely.
Healthcare professionals group these tasks into two categories. Basic activities of daily living (ADLs) are the essentials of physical survival: bathing, grooming, toileting, feeding yourself, and getting dressed. Instrumental activities of daily living (IADLs) require more complex thinking and organization: managing money, cooking meals, doing laundry, shopping, and arranging transportation. When someone struggles with several ADLs or IADLs, that’s typically the threshold for needing LTSS.
Where LTSS Is Delivered
LTSS falls into two broad settings: institutional care and home- and community-based services (HCBS).
Institutional care means nursing homes, long-term psychiatric facilities, and other residential settings with around-the-clock staffing. In 2023, about 1.5 million people received Medicaid-funded institutional LTSS, and nearly 64% of them were 65 or older.
HCBS is the alternative that most people prefer. It includes home health aides, personal care attendants, adult day programs, respite care for family caregivers, and home modifications like wheelchair ramps. The goal is to let someone stay in their own home or a small community residence rather than moving into a facility. HCBS is also significantly cheaper, usually less than half the cost of residential care. About 8.4 million people used Medicaid-funded HCBS in 2023, and the trend is firmly toward community-based care as the default model.
Who Uses LTSS
LTSS is not just for elderly people in nursing homes. The population is far more diverse than most people realize. Among Medicaid HCBS users in 2023, about a third were children and young adults age 20 or younger, another 25% were ages 21 to 44, and 22% were between 45 and 64. The largest group of HCBS users were people with mental health conditions or substance use disorders (42%), followed by people with autism, intellectual disabilities, or developmental disabilities (about 24%).
Institutional settings skew older and sicker. Nearly 64% of institutional LTSS users were 65 or older, and 62% had mental health conditions or substance use disorders. Many users fall into more than one category, reflecting the overlapping health challenges that drive the need for long-term support.
How LTSS Is Paid For
Medicaid is the dominant payer, covering over half of all LTSS spending in the United States. This makes LTSS one of Medicaid’s single largest cost categories. The rest is split among private long-term care insurance, out-of-pocket payments, and other public programs.
Medicare, by contrast, covers very little long-term care. It pays for skilled nursing facility stays only after a qualifying hospital stay of at least three consecutive inpatient days, only when you need daily skilled care like IV medications or physical therapy, and only for up to 100 days per benefit period. After day 100, you pay all costs. Medicare is designed for short-term recovery, not the kind of ongoing support that defines LTSS.
The cost gap between settings is substantial. A private room in a nursing home averaged about $108,000 per year (based on 2021 data), while 30 hours a week of home care averaged roughly $42,000 annually.
Qualifying for Medicaid-Funded LTSS
Because Medicaid is the primary payer, eligibility rules matter enormously. You generally need to meet both a functional requirement (demonstrating that you need help with daily activities) and a financial requirement. The financial side is strict.
The most common pathway for long-term care allows monthly income up to $2,901 for an individual in 2025 (300% of the federal SSI benefit level). Most states cap countable assets at $2,000 per person. Your home is usually excluded from the asset count, but federal rules set a home equity limit between $730,000 and $1,097,000, with most states using the lower figure.
Several other pathways exist. People who qualify for Supplemental Security Income (SSI) are generally eligible, with SSI’s own limits of $967 per month in income and $2,000 in assets. Working adults with disabilities can access Medicaid buy-in programs, which are more generous: the median income limit across states is about $3,261 per month with asset limits around $10,000. Rules vary significantly by state, so the same person might qualify in one state but not in a neighboring one.
The Cost of LTSS for Individuals
Even with Medicaid coverage, LTSS can be financially devastating. Many people don’t qualify for Medicaid but can’t afford to pay out of pocket for years of care. At $108,000 a year for a private nursing home room, savings can evaporate quickly. Home care is more affordable but still represents a major expense for most households.
Private long-term care insurance exists, but it covers a relatively small share of the population. Many people don’t buy it, either because premiums are high or because they assume Medicare will cover them. That assumption is one of the most common and costly misunderstandings in healthcare planning.
Growing Demand and Workforce Pressure
The need for LTSS workers is projected to grow by 40% between 2023 and 2038, from 2.35 million full-time equivalent professionals to 3.29 million. That growth applies to both direct care workers (home health aides, personal care attendants) and long-term care nurses.
The supply side looks far less optimistic. Bureau of Labor Statistics projections estimate that employment of home health and personal care aides will grow by just 17% over the next decade, roughly half the rate of demand growth. The workforce already faces high turnover, low pay, and physically demanding conditions. Family members and other unpaid caregivers fill enormous gaps, but quantifying that informal workforce and planning around it is difficult. The widening gap between demand and available workers is one of the most pressing challenges in LTSS today.