Long-Term Services and Supports (LTSS) is a broad system of assistance designed for individuals with chronic conditions or disabilities that impair their ability to function independently over an extended period. Its primary purpose is to address ongoing functional needs, not acute illnesses, distinguishing it from typical medical care received in a hospital or doctor’s office. The goal of LTSS is to help people maintain the highest possible degree of autonomy and quality of life in their preferred setting. This framework encompasses a variety of non-medical personal care and health-related services for people of all ages who require sustained support.
Defining Long-Term Services and Supports
LTSS refers to a wide range of paid and unpaid services that help individuals manage daily life tasks when they cannot perform them without assistance due to a physical or cognitive limitation. Unlike acute medical care, which aims to treat and cure a specific illness or injury, LTSS addresses chronic limitations that persist over extended periods. An individual’s need for these supports is determined by their functional status rather than the existence of a clinical diagnosis.
The focus of LTSS is on sustained personal assistance and supervision, meaning it is not intended to be rehabilitative or curative. This assistance helps people with disabilities or those aging with chronic illness to live as normally as possible. In the United States, more than six million people utilize paid LTSS, while many more receive unpaid care from family and friends.
Settings and Types of Care Provided
The assistance provided through LTSS is categorized by the specific tasks it helps with, primarily divided into Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). ADLs are fundamental self-care tasks, such as bathing, dressing, eating, and transferring. IADLs are more complex activities necessary for independent living in the community.
IADLs include tasks like managing finances, preparing meals, managing medication schedules, and using transportation. The level of functional limitation in these activities determines the intensity and type of LTSS an individual requires. Standardized assessments, such as the Katz Index for ADLs and the Lawton Scale for IADLs, are commonly used to measure a person’s need for support.
These services are delivered across a spectrum of settings, reflecting a trend toward supporting individuals in less restrictive environments. Home and Community-Based Services (HCBS) are a major component, covering assistance in a person’s private residence, adult day care programs, and personal care services. This approach prioritizes maximizing independence and community inclusion.
Institutional settings, such as Skilled Nursing Facilities (SNFs) and assisted living facilities, provide higher levels of support. SNFs offer 24-hour licensed nursing care and on-site physician services for individuals with significant functional limitations. Assisted living facilities provide a residential environment with supportive services, such as meal preparation and medication management, but do not offer the same level of complex medical care as SNFs.
Understanding Eligibility and Access
Access to publicly funded LTSS, particularly through Medicaid, depends on satisfying two main categories of state-specific criteria: functional and financial eligibility. The functional criteria determine the level of need, often referred to as the “level-of-care” criteria. This involves a formal assessment of an individual’s ability to perform ADLs and IADLs.
States use these functional assessments to confirm that an applicant requires the same level of care provided in an institutional setting, such as a nursing home, even if they are seeking HCBS. The specific threshold, such as needing assistance with two or three ADLs, varies significantly by state. This process ensures that LTSS resources are directed toward individuals with the most substantial functional impairment.
The financial criteria require that an applicant’s income and countable assets fall below established limits. For individuals who have assets above these thresholds, a process known as “spending down” is often required. This means the individual must use their personal savings and resources to pay for care until their assets are reduced to the state-mandated limit, at which point Medicaid coverage can begin.
While most Medicaid beneficiaries qualify based on income alone, eligibility for LTSS involves a separate, more complex set of rules for the elderly and people with disabilities. Many states allow individuals with incomes up to 300% of the Supplemental Security Income (SSI) benefit level to qualify for LTSS if they meet the functional criteria. The complexity of these rules, which vary based on whether the person is in a nursing home or receiving HCBS, often necessitates specialized guidance.
Funding Mechanisms for LTSS
Medicaid is the largest single source of public funding for LTSS in the United States, accounting for over 45% of all national spending on these services. This joint federal and state program covers mandatory nursing facility care and the majority of HCBS, which are often provided through optional state waivers. Medicaid’s role is important because other public programs offer limited coverage.
Medicare, the federal health insurance program for people aged 65 and older, does not function as a primary source for ongoing LTSS. Medicare generally covers only short-term, medically necessary skilled care, such as up to 100 days in a Skilled Nursing Facility following a qualifying hospital stay. It does not cover long-term personal care assistance in the home or the residential costs of assisted living.
For individuals who do not qualify for Medicaid, LTSS is financed through a mix of private options, with out-of-pocket spending being the second-largest source. Private savings and income are often depleted quickly due to the high cost of long-term care services. Long-Term Care Insurance (LTCI) is a private product purchased to protect against these costs, but its market penetration is relatively low. Other public sources, such as the Department of Veterans Affairs (VA) benefits, also contribute to LTSS financing for eligible veterans.
The majority of LTSS users rely heavily on either Medicaid or their own personal finances. The lack of affordable and comprehensive private insurance options means that Medicaid remains the financial safety net for a large portion of the population requiring long-term support.