Updated December 30, 2019
Overview of Long-Term Services and Supports
What Are Long-Term Services and
for individuals with intellectual and developmental
Supports?
disabilities. LTSS also includes the use of supports such as

special equipment, assistive devices, or technology.
Long-term services and supports (LTSS) refers to a broad

range of health and health-related services and supports
Who Needs Long-Term Services and
needed by individuals who lack the capacity for self-care
Supports?
due to a physical, cognitive, or mental disability or

condition. Often an individual’s disability or condition
The need for LTSS can affect persons of all ages—children
results in the need for hands-on assistance or supervision
born with disabling conditions, such as intellectual or
over an extended period of time. An individual’s need for
developmental disabilities; certain working-age adults with
LTSS may change over time as his or her needs or
inherited or acquired disabling conditions, such as mental
conditions change.
illness or traumatic brain injury; and the elderly with

chronic conditions or diseases, such as severe
cardiovascular disease or Alzheimer’s disease and related
About 14 million adults in the United States are in
dementia. The need for LTSS is generally measured,
need of LTSS, and over half (56%) are older adults
irrespective of age and diagnosis, by the presence of
aged 65 and over. Most are cared for in their own
functional limitations in the ability to perform basic
homes with the assistance of informal providers, such
personal care activities, known as activities of daily living
as family members or friends.
(ADLs), or by the need for supervision or guidance with

ADLs because of a mental or cognitive impairment.
LTSS is different from acute care services or post-acute

care services. In general, acute care services are health
ADLs refer to activities such as eating, bathing, using the
services provided for the prevention, diagnosis, or treatment
toilet, dressing, walking across a small room, and
of a medical condition. Acute care services are often
transferring (i.e., getting in or out of a bed or chair).
performed by licensed health care providers (e.g.,
Instrumental activities of daily living (IADLs) may also be
physicians) in a clinical setting, such as a doctor’s office or
used to measure a person’s need for LTSS. These activities
a hospital. In general, post-acute care services are health
are necessary for an individual’s ability to live
services provided over a short-term, typically after a
independently in the community. IADLs include activities
hospitalization to assist an individual with recovery from
such as preparing meals, managing money, shopping,
injury or illness and return to as normal a condition as
performing housework, using a telephone, doing laundry,
possible. While LTSS may be offered in combination with
getting around outside the home, and taking medications.
acute care or post-acute care services, LTSS is not intended

to treat or cure a medical condition. In contrast, LTSS
While the need for, use of, and costs associated with LTSS
provides assistance in maintaining or improving an optimal
vary across individuals over their lifespan, the probability
level of physical functioning and quality of life.
of needing LTSS increases with age. It is estimated that
70% of individuals who survive to age 65 develop a
LTSS includes a variety of services and supports that can be
disability serious enough to need LTSS, 40% will need care
provided in either community-based or institutional
for up to two years, and 38% will need care for four or
settings. Examples of community-based LTSS include a
more years. As the population ages, the demand for LTSS is
home health aide assisting a frail elderly person with daily
expected to increase. In addition, advances in medical care
personal care activities such as bathing or dressing, a
and supportive care are enabling younger persons with
contractor building a wheelchair ramp onto a home, or an
disabilities to live longer lives, requiring the delivery of
adult day program providing social and other related
services and supports for longer periods of time.
support services to a cognitively impaired individual. LTSS
can also be provided in a community-based residential care
Generally, public and private payers of LTSS determine
setting, such as a group home or assisted living facility
eligibility for LTSS in part based on the number of
(ALF) that provides housing and services such as meals,
limitations in specific ADLs. For example, publicly
laundry and housework, and assistance with medication.
financed programs that cover LTSS, such as Medicaid,

often use limitations in a certain number of ADLs to
LTSS also includes more intensive nursing care, such as
determine LTSS eligibility, among other criteria. State
nursing care provided to a ventilator-dependent child in a
Medicaid programs have flexibility in determining LTSS
private home or institutional setting. Individuals who have
need, sometimes referred to as “level-of-care” criteria,
severe physical and/or cognitive impairments may need the
where a high threshold for the level of care criteria might
24-hour supervision and convalescent care provided in an
require an individual to be dependent in four or more
institutional setting, such as a nursing home or institution
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link to page 2 Overview of Long-Term Services and Supports
ADLs, while a lower threshold might require dependency in
How Much Do Long-Term Services and
only two ADLs.
Supports Cost?
Under a private long-term care insurance (LTCI) policy,

limitations in the number of ADLs are the basis for
LTSS varies widely in terms of intensity and cost,
triggering benefit eligibility. Specifically, federal law
depending on an individual’s underlying conditions, the
provides federal tax benefits and minimum consumer
severity of his or her disabilities, the setting in which
protection standards for purchasers of “tax-qualified” LTCI
services are provided, and the caregiving arrangement (i.e.,
policies, as authorized by the Health Insurance Portability
paid care versus uncompensated care). The cost of
and Accountability Act of 1996 (HIPAA, P.L. 104-109; 42
obtaining paid assistance for these services, especially over
U.S.C. §7702B). HIPAA tax-qualified LTCI products are
a long period of time, may far exceed many individuals’
required to have defined benefit triggers for when the
financial resources. Moreover, public programs that finance
policy begins to pay long-term care benefits. In general,
this care, such as Medicaid, may not cover all the services
these triggers require policyholders to be certified by a
and supports an individual may need. Medicare does not
licensed health care practitioner as unable to perform at
cover most long-term care expenses. Large personal
least two ADLs for a minimum of 90 days or require
financial liabilities associated with paid LTSS can leave
substantial supervision due to severe cognitive impairment.
individuals in need of LTSS and their families at financial
risk.
Who Provides Paid Long-Term Services

and Supports?
For those receiving LTSS at home, the cost varies

depending on the amount and duration of care provided
The vast majority of LTSS is provided by caregivers, such
(see Table 1). Assuming care is provided 44 hours per
as family members, friends, and neighbors, who provide
week, the median annual cost for homemaker services was
uncompensated LTSS. However, some public programs
about $51,500 in 2019, while the median cost of home
may allow caregivers to be compensated to provide care
health aide services was over $52,600. Adult day health
and/or provide resources to further assist caregivers. A
centers have a median annual cost of $19,500 per year in
national survey published in 2015 found that 43.5 million
2019. These estimates are national figures and can vary
individuals in the United States served as unpaid family
widely by geographic region. For example, across the
caregivers to an adult or a child in the past 12 months.
United States, median daily rates for home health aide

services ranged from $107 to $188, and median daily rates
Paid LTSS is provided by individuals employed by an
for adult day health centers ranged between $32 and $154.
organization or agency, such as a nursing home or home
health care agency, or by self-employed individuals who
Residential settings that provide housing and services as
are hired by an individual or family member. The National
well as institutional settings tend to have higher annual
Center for Health Statistics estimated that about 65,600
costs than home care services, on average. Assisted living
paid, regulated long-term care services providers served
facilities had a median annual cost of about $48,600, while
over 8.3 million individuals in 2016. These providers
the median annual cost of nursing home care was over
include an estimated 28,900 residential care communities,
$90,100 for a semi-private room and $102,200 for a private
15,600 nursing homes, 12,200 home health agencies, and
room in 2019. As with estimated costs for home care
4,600 adult day health centers. With the exception of adult
services, these estimates are national figures and can vary
day health centers, the ownership status of most long-term
widely by geographic region. For example, across the
care providers was for-profit.
United States, the median daily rate for a one-bedroom,
single occupancy unit in an assisted living facility ranged
Licensed or skilled health care workers that provide LTSS
between $95 and $371, while the median daily rate in a
include registered or licensed nurses, physical and
private nursing home room ranged between $185 and $994.
occupational therapists, and social workers. However, most
LTSS is provided by nonlicensed providers such as certified
Table 1. Median Rates for LTSS Providers, 2019
nurse assistants, home health aides, and personal care aides.
The Bureau of Labor Statistics (BLS) estimated that there
Daily
Monthly
Annual
were 3.3 million home health aides and personal care aides

Rate
Rate
Rate
in 2018. This likely underestimates the number of home
Nursing Home (Private)
$280
$8,517
$102,200
care workers, as it does not include self-employed workers.
BLS estimates another 1.6 million nursing assistants and
Home Health Aide
$144
$4,385
$52,624
orderlies in 2018, which is an overestimate of the LTSS
nursing assistant workforce, as it includes individuals who
Homemaker Services
$141
$4,290
$51,480
work in acute care hospitals as well as long-term care
Assisted Living Facility
$133
$4,051
$48,612
settings. Between 2018 and 2028, home health aides and
personal care aides are projected to be among the top 20
Adult Day Health Care
$75
$1,625
$19,500
fastest growing occupations, both in terms of rate of growth
Source: Genworth Financial, Genworth 2019 Cost of Care Survey,
(a 36% increase) and numerical growth, with an increase of
October, 2019.
1.2 million new jobs. This is faster than the average rate of
growth for all occupations at 5%. Nursing assistants are
Kirsten J. Colello, Specialist in Health and Aging Policy
projected to grow by 9%, with a projected increase of
138,000 new nursing assistants over the same time period.
IF10427
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Overview of Long-Term Services and Supports


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