LTSS stands for Long-Term Services and Supports, a broad category of healthcare that helps people who have difficulty caring for themselves due to age, disability, or chronic health conditions. It covers everything from help with bathing and eating to managing medications and finances. Unlike most medical care, LTSS isn’t about treating an illness and getting better. It’s ongoing assistance that helps people function day to day, sometimes for years or the rest of their lives.
What LTSS Actually Covers
LTSS spans both medical and non-medical care. The medical side includes things like skilled nursing, medication management, and physical therapy. But a large portion of LTSS is hands-on help with basic tasks that most people do without thinking: getting dressed, bathing, using the toilet, eating, and moving from a bed to a chair. These are known as Activities of Daily Living, or ADLs.
There’s also a second layer of more complex tasks called Instrumental Activities of Daily Living (IADLs). These include cooking meals, managing money, shopping for groceries, using a phone, doing laundry, and getting transportation to appointments. Someone might be physically capable of standing and walking but unable to manage their finances or prepare food safely. LTSS covers both levels of need.
Who Uses These Services
LTSS isn’t just for elderly people in nursing homes, though that’s the image most people have. In 2023, roughly 8.4 million people used Medicaid-funded home and community-based LTSS, and the majority of them were younger than 65. About a third were 20 or younger, and another quarter were between 21 and 44. The largest group of home-based LTSS users were people with mental health conditions or substance use disorders (42 percent), followed by people with autism, intellectual disabilities, or developmental disabilities (about 24 percent).
Institutional care tells a different story. Among the 1.5 million people receiving LTSS in facilities like nursing homes, nearly 64 percent were 65 or older. So while nursing homes skew heavily toward older adults, the broader LTSS system serves a much wider population than most people realize.
Where Services Are Delivered
LTSS is delivered through two main models: home and community-based services (HCBS) or facility-based care. The actual services available under each model are largely the same. The difference is where you live and who comes to you.
With HCBS, you stay in your own home or a family member’s home. Caregivers visit to provide the help you need, and you travel to community providers for additional services. In some states, family members can even be certified and paid as caregivers. This model is designed to keep people in familiar surroundings and connected to their communities.
Facility-based care means living in a place specifically set up to provide LTSS, like a nursing home or residential care facility. Professional staff work on-site, and most services are delivered right where you live. For people with intensive daily needs or safety concerns that make living at home impractical, facility-based care provides round-the-clock support.
Federal policy has increasingly pushed toward home and community-based care over institutional placement, and the numbers reflect this. HCBS users outnumber institutional users by more than five to one.
How People Qualify
Eligibility for publicly funded LTSS, primarily through Medicaid, is based on two things: financial need and functional ability. Having a specific diagnosis isn’t what qualifies you. Instead, states use assessment tools that measure how much help you actually need with daily tasks. This is called a “level of care” determination, and it typically requires that your needs are serious enough to warrant the kind of support you’d get in a nursing facility.
On the financial side, you generally need to meet Medicaid income and asset limits. In 42 states plus Washington, D.C., people who receive Supplemental Security Income (SSI) automatically qualify for full Medicaid benefits, including LTSS, as long as they meet the functional criteria. SSI eligibility itself requires being 65 or older, or having a significant impairment that prevents gainful work (for adults 18 to 64), or having marked functional limitations (for children).
How LTSS Is Paid For
This is where things get complicated, and where many people are caught off guard. Medicare does not pay for long-term care. Most private health insurance doesn’t either. If you need ongoing help with daily activities, Medicare won’t cover it, and you’re responsible for 100 percent of the cost.
Medicaid is the single largest payer for LTSS in the country. Combined with Medicare (which covers some limited skilled nursing stays, not true long-term care), public programs account for about 63.6 percent of all LTSS spending nationwide. Medicaid’s share alone has grown to 45.6 percent of total LTSS costs.
For people who don’t qualify for Medicaid, the options are limited. Private long-term care insurance exists but remains relatively uncommon. It’s expensive, and premiums rise significantly the older you are when you buy it. Private health insurance plans sometimes cover medically necessary long-term care, but typically only for up to 100 days. About half of all nursing home patients in the U.S. pay out of their own savings. Many people spend down most of their assets on care before they become poor enough to qualify for Medicaid, a process that’s both financially and emotionally draining.
The cost of care is substantial. Full-time home care runs roughly $5,900 to $6,500 per month at the national median. Nursing home care is significantly more expensive. Some people use reverse mortgages or other financial tools to bridge the gap, but there’s no easy answer for most families.
The Workforce Challenge
LTSS depends heavily on direct care workers: home health aides, personal care assistants, and nursing facility staff. This workforce is projected to reach 6 million by 2032, but that number still falls short of estimated needs. The gap is widening as the population ages and fewer family members are available to provide unpaid care.
The pandemic hit this sector especially hard, and recovery has been uneven. By 2024, most healthcare sub-sectors had regained their pre-pandemic employment levels, but elderly care was still down 1 percent and skilled nursing facilities were down 8.3 percent. For people trying to arrange LTSS for themselves or a loved one, this can mean longer wait times, fewer provider options, and difficulty finding reliable in-home help.