Who Pays For LTSS?

Who Pays For LTSS?

Tribal LTSS programs often use multiple revenue sources to promote sustainable funding. Listed below are pros, cons, and other factors to consider for these common LTSS payers:

Medicaid, Medicare, Indian Health Service (IHS), private insurance, private pay, tribal support, and grants.


Medicaid, the primary funder for LTSS, is a joint federal and state program that helps with medical costs for some people who have limited resources. It also covers things that are not usually covered by Medicare, like personal care services.

Learn more about Medicaid.


  • Funding is based on eligibility and services, not budget limits
  • States can get 100% federal reimbursement (100% FMAP) for Medicaid services provided through tribal health facilities – this benefit gives tribes an advantage in negotiating with states to receive enhanced reimbursement for services. Learn more about 100% FMAP
  • Medicaid funding includes home- and community-based services like PACE and MFP


  • Non-Indians served at tribal facilities are reimbursed at the state's usual FMAP, meaning the state's only a portion of the cost
  • State Medicaid plans may not reimburse all services your program provides or intends to provide

Medicaid Waivers

Waivers are menus of state-defined services that commonly support home- and community-based services and cover certain services for people who otherwise would not be eligible.

People who receive waiver services must meet medical, financial, or geographical qualifications (such as living in a certain county. Waivers can be very broad or very narrow.

LTSS Resources icon

Waiver resources


Medicare is the federal health care coverage program for people who are 65 or older and certain younger people with disabilities or specific diseases.

Learn more about Medicare.


  • Provides up to 100 days of long-term care in a skilled nursing facility, hospice care, or some home health care settings
  • Reliable revenue source for transitional care, which is needed when a patient moves from a care facility back to their community (or from the community to a facility)


  • Not all patients qualify. Medicare only supports care for patients over 65 or those with disabilities, end-stage renal disease, or amyotrophic lateral sclerosis
  • Unskilled care, like daily living support or transportation, is not covered
  • Skilled nursing or home health care is covered on a limited basis, not for long-term needs
  • Medicare certification is often difficult to get

Indian Health Service

Because of the Indian Health Care Improvement Act reauthorization, tribes can now include LTSS in their self-governance agreements with IHS.


  • LTSS is now explicitly identified as an allowable expense for IHS funding
  • Tribal facilities can use existing IHS funds to cover positions and services not reimbursable from other funders
  • IHS-supported positions, like community health representatives or visiting nurses, can assist with non-reimbursable LTSS care
  • IHS funds can support LTSS services not covered by a state's waiver program, Medicaid, or Medicare
  • Overhead and indirect costs are included in tribes' contracts/compacts with IHS, unlike other revenue sources that only finance direct care


  • No funds are mandated to add LTSS to allowable IHS services, so LTSS resources must come from existing contract/compact funding

Policy background

The 2010 reauthorization of the Indian Health Care Improvement Act defines LTSS as a service IHS can cover, meaning tribes can include LTSS in their self-governance agreements with IHS.

For a state to receive 100% federal reimbursement for tribally provided LTSS, a tribe's IHS funding agreement must explicitly include LTSS.

Long-term care coverage and private health care coverage

Long-term care coverage specifically covers LTSS. It is fairly new, so what it covers and its costs may change over time.

Private health care coverage is often provided by employers or purchased through the Health Insurance Marketplace, and it usually covers long-term care that is medically necessary for up to 100 days.


  • Long-term care coverage is designed to support people with long-term care needs
  • Recent trends in federal policies, including those related to health care coverage, promote home- and community-based models instead of focusing only on facility-based care
  • Private health care coverage often covers some long-term care, although the coverage is limited


  • AI/AN populations report lower percentages for private health care coverage, so funding source might not be reliable
  • Covered services vary widely by plan
  • Long-term care coverage can be quite costly, so many people do not purchase it
  • Long-term care coverage gets more expensive the older you are when you buy it, so current LTSS patients are less likely to have it

Private pay

Many people pay for their own long-term care. About half of all U.S. nursing home patients pay for the costs of long-term care out of their own savings.


  • Paying privately for home= and community-based services can help people stay in their homes longer
  • If a person's savings run out, they may then be able to qualify for Medicaid
  • There are many options for paying privately, such as reverse mortgages, which enable homeowners to receive money against the value of their homes without selling them


  • Those who have money saved may spend most or all of it on long-term care before they are eligible for Medicaid or other assistance
  • Many people who need care may not have enough money to pay privately at all

Tribal support

For the tribe to support LTSS financially, it must be a priority of tribal leadership.


  • Tribal support allows for fewer restrictions on what LTSS funds can be used for
  • Tribal support empowers tribal communities to have more control over their own long-term care programs


  • Getting tribal leadership to support your program as a priority could mean spending much time and effort educating the community and advocating for funding
  • Often, tribes need to change the tribal code and/or budget to incorporate LTSS funding

See the Tribal Leaders section for guidance on gaining tribal leader support.


While grants can help kick off a new LTSS program or support certain projects within a program, relying on grants as a sole funding source is not recommended.


  • Grants provide assistance for creating a new project or starting a program


  • Grant funds provide money for a limited amount of time
  • Grants may also require that the use of funds be limited to a specific set of activities
  • Priorities of an individual grant organization may change over time, meaning you often cannot go back to the same grantor for more funding once a grant ends



Page Last Modified:
09/06/2023 04:57 PM