Long-Term Services & Support
The Medicaid program allows for the coverage of Long Term Care Services through several vehicles and over a continuum of settings. This includes Institutional Care and Home and Community Based Long Term Services and Supports. Information on those topics is below. For more information on additional community based topics, see the link to the right.
Institutional Long Term Care
Medicaid covers certain inpatient, comprehensive services as institutional benefits. The word “institutional” has several meanings in common use, but a particular meaning in federal Medicaid requirements. In Medicaid coverage, institutional services refers to specific benefits authorized in the Social Security Act. These are hospital services, Intermediate Care Facilities for People with Mental Retardation (ICF/MR), Nursing Facility (NF), Preadmission Screening & Resident Review (PASRR), Inpatient Psychiatric Services for Individuals Under Age 21, and Services for individuals age 65 or older in an institution for mental diseases.
Institutional benefits share the following characteristics:
- Institutions are residential facilities, and assume total care of the individuals who are admitted.
- The comprehensive care includes room and board. Other Medicaid services are specifically prohibited from including room and board.
- The comprehensive service is billed and reimbursed as a single bundled payment. (Note that states vary in what is included in the institutional rate, versus what is billed as a separately covered service, for example physical therapy may be reimbursed as part of the bundle or as a separate service.)
- Institutions must be licensed and certified by the state, according to federal standards.
- Institutions are subject to survey at regular intervals to maintain their certification and license to operate.
- Eligibility for Medicaid may be figured differently for residents of an institution, and therefore access to Medicaid services for some individuals may be tied to need for institutional level of care.
Community Based Long-Term Services & Supports
CMS is working in partnership with states, consumers and advocates, providers and other stakeholders to create a sustainable, person-driven long-term support system in which people with disabilities and chronic conditions have choice, control and access to a full array of quality services that assure optimal outcomes, such as independence, health and quality of life.
The programs and partnerships contained in this section are aimed at achieving a system that is:
- Person-driven: The system affords older people, people with disabilities and/or chronic illness the opportunity to decide where and with whom they live, to have control over the services they receive and who provides the services, to work and earn money, and to include friends and supports to help them participate in community life.
- Inclusive: The system encourages and supports people to live where they want to live with access to a full array of quality services and supports in the community.
- Effective and Accountable: The system offers high quality services that improve quality of life. Accountability and responsibility is shared between public and private partners and includes personal accountability and planning for long-term care needs, including greater use and awareness of private sources of funding.
- Sustainable and Efficient: The system achieves economy and efficiency by coordinating and managing a package of services paid that are appropriate for the beneficiary and paid for by the appropriate party.
- Coordinated and Transparent: The system coordinates services from various funding streams to provide a coordinated, seamless package of supports, and makes effective use of health information technology to provide transparent information to consumers, providers and payers.
- Culturally Competent: The system provides accessible information and services that take into account people's cultural and linguistic needs.
For more information on Community Based topics, see the links to the right.