Medicaid has historically relied on institutional settings to provide long-term services and supports (LTSS) to beneficiaries. However, over the last two decades, federal and state policymakers have focused on rebalancing LTSS away from institutional settings and toward home and community-based services (HCBS). The COVID-19 pandemic has accelerated federal and state interest to promote the use of HCBS over institutional services.
States have made progress toward rebalancing LTSS, although some states have been more successful than others. To better understand the factors that affect states’ efforts to rebalance their LTSS systems, barriers, and opportunities to address those barriers, MACPAC contracted with RTI International to conduct case studies of five states (Louisiana, Mississippi, New Jersey, North Dakota, and West Virginia). These states were selected because of their low rates of HCBS spending, variation in the use of HCBS state plan and waiver options, population density, participation in the Balancing Incentive Program or Money Follows the Person, and adoption of Medicaid managed LTSS. This report reviews the findings from interviews with federal officials, case study state officials, and national and case study state stakeholders involved with Medicaid LTSS systems and beneficiaries.