Updated August 5, 2021
Overview of Long-Term Services and Supports
What Are Long-Term Services and
disabilities. LTSS also includes the use of supports such as
Supports?
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
The need for LTSS can affect persons of all ages —children
condition. Often an individual’s disability or condition
born with disabling conditions, such as intellectual or
results in the need for hands-on assistance or supervision
developmental disabilities ; certain working-age adults with
over an extended period of time. An individual’s need for
inherited or acquired disabling conditions, such as mental
LTSS may change over time as his or her needs or
illness or traumatic brain injury; and the elderly with
conditions change.
chronic conditions or diseases, such as severe

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


LTSS is different from acute care services or post-acute
ADLs refer to activities such as eating, bathing, using the
care services. In general, acute care services are health
toilet, dressing, walking across a small room, and
services provided for the prevention, diagnosis, or treatment
transferring (i.e., getting in or out of a bed or chair).
of a medical condition. Acute care services are often
Instrumental activities of daily living (IADLs) may also be
performed by licensed health care providers (e.g.,
used to measure a person’s need for LTSS. These activities
physicians) in a clinical setting, such as a doctor’s office or
are necessary for an individual’s ability to live
a hospital. In general, post-acute care services are health
independently in the community. IADLs include activities
services provided over a short-term, typically after a
such as preparing meals, managing money, shopping,
hospitalization to assist an individual with recovery from
performing housework, using a telephone, doing laundry,
injury or illness and return to as normal a condition as
getting around outside the home, and taking medications.
possible. While LTSS may be offered in combination with

acute care or post-acute care services, LTSS is not intended
While the need for, use of, and costs associated with LTSS
to treat or cure a medical condition. In contrast, LTSS
vary across individuals over their lifespan, the probability
provides assistance in maintaining or improving an optimal
of needing LTSS increases with age. It is estimated that
level of physical functioning and quality of life.
more than half (56%) of Americans who survive to age 65
will develop a disability serious enough to need LTSS, 10%
LTSS includes a variety of services and supports that can be
will need care for less than a year, and 22% will need care
provided in either community-based or institutional
for five or more years. As the population ages, the demand
settings. Examples of community-based LTSS include a
for LTSS is expected to increase. In addition, advances in
home health aide assisting a frail elderly person with daily
medical care and supportive care are enabling younger
personal care activities such as bathing or dressing, a
persons with disabilities to live longer lives, requiring the
contractor building a wheelchair ramp onto a home, or an
delivery of services and supports for longer periods of time.
adult day program providing social and other related
support services to a cognitively impaired individual. LTSS
Generally, public and private payers of LTSS determine
can also be provided in a community-based residential care
eligibility for LTSS in part based on the number of
setting, such as a group home or assisted living facility
limitations in specific ADLs. For example, publicly
(ALF) that provides housing and services such as meals,
financed programs that cover LTSS, such as Medicaid,
laundry and housework, and assistance with medication.
often use limitations in a certain number of ADLs to

determine LTSS eligibility, among other criteria. State
LTSS also includes more intensive nursing care, such as
Medicaid programs have flexibility in determining LTSS
nursing care provided to a ventilator-dependent child in a
need, sometimes referred to as “level-of-care” criteria,
private home or institutional setting. Individuals who have
where a high threshold for the level of care criteria might
severe physical and/or cognitive impairments may need the
require an individual to be dependent in four or more
24-hour supervision and convalescent care provided in an
ADLs, while a lower threshold might require dependency in
institutional setting, such as a nursing home or institution
two ADLs.
for individuals with intellectual and developmental

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link to page 2 Overview of Long-Term Services and Supports
Under a private long-term care insurance (LTCI) policy,
How Much Do Long-Term Services and
limitations in the number of ADLs are the basis for
Supports Cost?
triggering benefit eligibility. Specifically, federal law
LTSS varies widely in terms of intensity and cost,
provides federal tax benefits and minimum consumer
depending on an individual’s underlying conditions, the
protection standards for purchasers of “tax-qualified” LTCI
severity of his or her disabilities, the setting in which
policies, as authorized by the Health Insurance Portability
services are provided, and the caregiving arrangement (i.e.,
and Accountability Act of 1996 (HIPAA, P.L. 104-191; 26
paid care versus uncompensated care). The cost of
U.S.C. §7702B). HIPAA tax-qualified LTCI products are
obtaining paid assistance for these services, especially over
required to have defined benefit triggers for when the
a long period of time, may far exceed many individuals’
policy begins to pay long-term care benefits. In general,
financial resources. Moreover, public programs that finance
these triggers require policyholders to be certified by a
this care, such as Medicaid, may not cover all the services
licensed health care practitioner as unable to perform at
and supports an individual may need. Medicare does not
least two ADLs for a minimum of 90 days or require
cover most long-term care expenses. Large personal
substantial supervision due to severe cognitive impairment.
financial liabilities associated with paid LTSS can leave

individuals in need of LTSS and their families at financial
Who Provides Paid Long-Term Services
risk.
and Supports?

The vast majority of LTSS is provided by caregivers, such
For those receiving LTSS at home, the cost varies
as family members, friends, and neighbors, who provide
depending on the amount and duration of care provided
uncompensated LTSS. Some public programs may allow
(see Table 1). Assuming care is provided for 44 hours per
caregivers to be compensated to provide care and/or
week, per industry guidance, the median annual cost for
provide resources to further assist caregivers. A national
homemaker services was about $53,800 in 2020, while the
survey published in 2020 estimated that 53 million adults in
median cost of home health aide services was over $54,900.
the United States served as family caregivers to an adult or
Adult day health centers have a median annual cost of
a child with special needs in the past 12 months.
$19,200 per year in 2020. These estimates are national

figures and can vary widely by geographic region. For
Paid LTSS is provided by individuals employed by an
example, median daily rates for home health aide services
organization or agency, such as a nursing home or home
ranged across the 50 states and the District of Columbia
health care agency, or by independent providers who are
(DC) from $107 to $195, and median daily rates for adult
hired by an individual or family member. The National
day health centers ranged between $30 and $160.
Center for Health Statistics estimated that about 65,600
paid, regulated long-term care services providers served
Residential settings that provide housing and services as
over 8.3 million individuals in 2016. These providers
well as institutional settings tend to have higher annual
include an estimated 28,900 residential care homes and
costs than home care services, on average. Assisted living
communities, 15,600 nursing homes, 12,200 home health
facilities had a median annual cost of $51,600, while the
agencies, and 4,600 adult day health centers. With the
median annual cost of nursing home care was about
exception of adult day health centers, the ownership status
$93,100 for a semi-private room and $105,900 for a private
of most long-term care providers was for-profit.
room in 2020. As with estimated costs for home care
services, these estimates are national figures and can vary
Licensed or skilled health care workers that provide LTSS
widely by geographic region. For example, the median
include registered or licensed nurses, physical and
daily rate for a one-bedroom, single occupancy unit in an
occupational therapists, and social workers. However, most
assisted living facility ranged across states and DC from
LTSS is provided by nonlicensed providers who are
$99 to $220; the median daily rate in a private nursing
generally referred to as professional caregivers or direct
home room ranged from $189 to $1,196.
care workers and include home health aides, personal care
aides, and nursing assistants. PHI, a national policy and
Table 1. Median Rates for LTSS Providers, 2020
advocacy organization on the direct care workforce,
estimates about 4.6 million direct care workers in 2019.
Daily
Monthly
Annual
Among those, about 2.4 million worked in home care;

Rate
Rate
Rate
730,000 in residential care homes; 570,000 in nursing
homes; and 900,000 in other industries. However, this
Nursing Home (Private)
$290
$8,821
$105,850
likely underestimates the number of direct care workers, as
Home Health Aide
$150
$4,576
$54,912
it does not include those privately employed by consumers,
the so-called “grey market,” which is difficult to measure.
Homemaker Services
$147
$4,481
$53,768
Between 2019 and 2029, the Bureau of Labor Statistics
Assisted Living Facility
$141
$4,300
$51,600
estimates that home health aides and personal care aides are
projected to be among the top 20 fastest growing
Adult Day Health Care
$74
$1,603
$19,240
occupations, both in terms of rate of growth (a 34%
Source: Genworth Financial, Genworth 2020 Cost of Care Survey,
increase) and numerical growth, with an increase of 1.2
October, 2020.
million new jobs. This is faster than the average rate of
growth for all occupations at 4%. Nursing assistants are
Kirsten J. Colello, Specialist in Health and Aging Policy
projected to grow by 8%, with a projected increase of
120,000 new nursing assistants over the same time period.
IF10427
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Overview of Long-Term Services and Supports


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