Tipping the Balance: The Balancing Incentive Program and State Progress on Rebalancing Their Long-Term Services and Supports

The National Evaluation of the Money Follows the Person Demonstration Reports from the Field #18
Publisher: Cambridge, MA: Mathematica Policy Research
Sep 30, 2015
Rebecca Sweetland Lester, Carol V. Irvin, Abigail Mosca, and Ciara Bradnan

Key Findings:

  • Preliminary data suggested that 11 of the 18 participating states had achieved their balancing benchmark a year before the Balancing Incentive Program was scheduled to end.
  • The Balancing Incentive Program states have been increasing the share of total LTSS expenditures for community services more quickly than have nonparticipating states.
  • Of the Balancing Incentive Program states that had achieved the balancing benchmark by 2014, state plan personal care services represented a notable and growing proportion of expenditures, suggesting that state plan services have made important contributions to states’ rebalancing success.
  • Survey results and interviews suggest that the Money Follows the Person Rebalancing Demonstration has been a key factor in the success of state rebalancing initiatives.

The Balancing Incentive Program, like the Money Follows the Person Rebalancing Demonstration, is designed to help states shift the balance of Medicaid LTSS by increasing opportunities for people to receive care in the community rather than in an institution.

The Balancing Incentive Program, authorized by Section 10202 of the Affordable Care Act, was established for states that in federal fiscal year 2009 were spending more on institutional care than they were on community-based LTSS. In exchange for additional federal funds, Balancing Incentive Program states must implement several structural changes to their LTSS systems and reach the “balancing benchmark” where community-based LTSS account for at least 50 percent of total LTSS spending (or 25 percent for Mississippi) by September 30, 2015.

The report examines the progress Balancing Incentive Program states have made in increasing the share of their LTSS dollars spent on community-based services one year before the program end date. It contains an analysis of expenditure trends in participating states, including an exploration of trends in the use of specific service types in states that have been more successful in increasing the community-based share of LTSS expenditures. It also presents state perspectives on the factors that most contributed to their success in increasing the community-based share of LTSS spending, with a focus on the contributions of the Balancing Incentive Program.


Research and Evaluation of the Money Follows the Person (MFP) Demonstration Grants


U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services

Time Frame


Senior Staff

Carol Irvin
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