Medicaid enrollees increasingly are receiving long-term services and supports (LTSS) through home and community-based services (HCBS). To date analyses of service use and spending associated with HCBS users have not taken a detailed look at the types of HCBS used and the individual characteristics of users. This MACPAC-commissioned report describes the characteristics and service use of Medicaid enrollees who used HCBS, and analyzes Medicaid spending for these HCBS users, by state and over time. This analysis used Medicaid Analytic eXtract (MAX) claims data spanning from 2010 to 2013. The analysis uses the HCBS taxonomy, a classification system consisting of 18 categories, to describe HCBS use and spending with more detail than was possible in the past. This analysis compares spending, utilization, and characteristics of all HCBS users with high-cost users, defined in our analysis as the 3 percent of HCBS users with the highest spending on HCBS in each state. High-cost users accounted for 30 percent of HCBS spending overall in 2012, the most recent year for which data were available for the greatest number of states. Round-the-clock services were the most commonly used HCBS category for high-cost users, and were used by at least half of high-cost users in 27 of 44 states in 2012.