Medicaid Long Term Services and Supports Annual Expenditures Report: Federal Fiscal Year 2020

Medicaid Long Term Services and Supports Annual Expenditures Report: Federal Fiscal Year 2020

Published: Jun 09, 2023
Publisher: Mathematica
Associated Project

Long-term Services and Supports Expenditure Reports Project

Time frame: 2019-2024

Prepared for:

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


Caitlin Murray

Michelle Eckstein

Key Findings
  • National Medicaid LTSS expenditures totaled $199.4 billion in FY 2020, with HCBS accounting for $124.6 billion (62.5 percent) and institutional services accounting for $74.8 billion (37.5 percent).
  • Spending on LTSS as a share of total Medicaid expenditures has declined from 47 percent in FY 1988 to 33 percent in FY 2020. There are several factors behind this decline, including state LTSS system rebalancing initiatives that promote the increased use of more cost-effective HCBS and increased spending for Medicaid populations that do not use LTSS.
  • The percentage of HCBS expenditures out of total Medicaid LTSS expenditures has steadily increased over the last three decades, reaching 62.5 percent in FY 2020. This was an all-time high and represented a 3.9 percentage point increase from FY 2019.
  • The absolute amount spent on MLTSS programs increased more than eightfold in the past two decades, climbing from $6.7 billion in FY 2008 to $57 billion in FY 2020. The growth in expenditures reflects more states using MLTSS, rising from 8 in FY 2006 to 25 states in FY 2020, and more people receiving LTSS through these programs.

Long-term services and supports (LTSS) encompass a wide range of medical and nonmedical services and supports for people with physical, intellectual, mental health and substance use disorders (MH/SUD), or other disabilities or conditions. These can include institutional care, such as that provided in nursing facilities, intermediate care facilities for individuals with intellectual or developmental disabilities (ICF/IDD), and mental health facilities, as well as home and community-based services (HCBS), such as personal care and home health. Medicaid is the primary payer of LTSS. Over the past several decades, federal and state initiatives and consumer preferences have led to shifts in Medicaid LTSS expenditure patterns across settings and service types, including increases in HCBS expenditures.

This report is the latest in a series of reports, sponsored by the Centers for Medicare & Medicaid Services (CMS), on Medicaid LTSS expenditures. It contains detailed information about Medicaid LTSS expenditures for federal fiscal year (FY) 2020 (October 1, 2019, to September 30, 2020) at the national and state levels by service category, type of LTSS (institutional and HCBS), and payment model. The last half of the FY 2020 period covers the first six months of the COVID-19 Public Health Emergency (PHE) in 2020, which had a major impact on the use of all health care services, including LTSS paid by Medicaid.

The accompanying Excel attachments contain LTSS service category expenditures, state data tables, managed LTSS expenditures, and additional non-LTSS expenditures for several relevant categories. The report is based on data from several sources, including Medicaid CMS-64 expenditure reports, state-reported managed LTSS (MLTSS) expenditures, Money Follows the Person (MFP) worksheets for proposed budgets, CMS 372 report data for section 1915(c) waiver programs, and U.S. Census data.

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