Medicaid enrollees increasingly are receiving long-term services and supports (LTSS) in the home and community. In 2016, for the fourth consecutive year, more than half of Medicaid spending for LTSS was for home- and community-based services (HCBS) rather than institutional care (Eiken et al. 2018). This shift is the result of a variety of factors, including efforts by federal and state policymakers to rebalance Medicaid LTSS spending towards HCBS in order to curb spending growth and meet beneficiary preferences to live in the community. Medicaid spending on HCBS users remains disproportionately high relative to their share of enrollment. In 2013, the approximately 4 percent of Medicaid enrollees who used HCBS accounted for 23.9 percent of Medicaid fee-for-service (FFS) spending on all services ($97.8 billion of $409.3 billion) (MACPAC 2017).