Fact Sheets

Long-term Services and Supports (LTSS) Rebalancing Toolkit Fact Sheet


The Centers for Medicare & Medicaid Services (CMS) is releasing the Long-term Services and Supports (LTSS) Rebalancing Toolkit to support states in their efforts to expand and enhance home and community-based services (HCBS) and to rebalance, or recalibrate, LTSS from institutional to community-based systems. CMS remains steadfast in its commitment to ensuring that states have the necessary tools to design, implement, and advance LTSS “rebalancing” – achieving a more equitable balance between the share of spending and use of services and supports delivered in home and community-based settings relative to institutional care.

The toolkit advances CMS’s long-standing priority to support state flexibility to develop a broad range of HCBS; to reinforce the delivery of high quality and person-centered care; and to facilitate progress toward community integration of older adults and individuals with disabilities. By using this toolkit, states and other key stakeholders can help to accelerate the use of HCBS over institutional services, especially as states seek strategies and solutions to address the high rates of COVID-19 infection and death among nursing facility residents.

The toolkit identifies promising state models and practices for strengthening state infrastructure to increase transitions from institutional settings to community-based settings; prevent or delay institutionalization; and improve community living for individuals eligible for Medicaid HCBS.

The toolkit contains four modules that provide: 

  • State strategies to increase the share of LTSS provided in community-based settings;
  • Tools designed to assist states with policy and programmatic strategies;
  • Case studies of innovative programs and creative ways states are leveraging available federal authorities to transform LTSS systems; and
  • Links to relevant resources.

The toolkit uses a variety of communication methods, including narrative text, charts, and figures, to help states plan and implement strategies to improve HCBS programs and overall LTSS systems.

Module I: Background on HCBS and Institutional Services

Provides historical context on the evolution of LTSS reform initiatives and a snapshot of LTSS rebalancing and demographic trends. Over the past several decades, states have used several federal authorities, as well as federally funded grant programs, to develop a broad range of HCBS to provide alternatives to institutionalization for eligible Medicaid beneficiaries. HCBS expenditures, relative to total Medicaid LTSS expenditures, have steadily increased over the last three decades, but this trend has slowed in recent years. In addition, the number of adults age 65 and older is expected to more than double between 2014 and 2060, with the largest increase expected from 2020 to 2030. By 2030, one in five U.S. residents will be age 65 or older.

Module II: Advancing State Home and Community Based Services Rebalancing Strategies

Describes key elements of HCBS systems that are economically sustainable, equitable across the broad range of people with LTSS needs, and continuously improving in HCBS quality and access. Several interrelated key elements of an effective system to advance HCBS are: (1) person-centered planning and services; (2) No Wrong Door systems; (3) community transition support; (4) direct service workforce and caregivers; (5) housing to support community-based living options; (6) employment support; and (7) convenient and accessible transportation options. In addition, this module discusses data based decision making in HCBS, stakeholder engagement, quality improvement, and financing approaches.

Module III: Current Flexibility under Medicaid to Support State Rebalancing Strategies

Describes the various Medicaid authorities from which states can choose to cover HCBS and provides state examples of how these Medicaid authorities can advance rebalancing strategies. This module provides an overview of programs and services to support Medicaid beneficiaries to transition from medical institutions to the community including services such as personal care and case management services that help individuals achieve community living goals. In addition, this module profiles states’ innovative HCBS programs and services that can foster efficiency, reduce and contain costs, and improve health outcomes for Medicaid beneficiaries. Further, institutional tools for advancing rebalancing, such as the Preadmission Screening & Resident Review (PASRR), are featured.

Module IV: State Strategies to Rebalancing LTSS Systems

Provides examples of innovative state models of care and strategies to reform and recalibrate LTSS systems and to expand and enhance HCBS. This module describes how some states are testing new eligibility groups and benefit packages for individuals at risk of needing Medicaid LTSS in the future. In addition, case studies show how some states decrease the use of institutional care and incentivize community-based care through “bed buy-back” programs, repurposing long-term care facilities, and supporting new business models for direct service workers.