Managed Long-Term Services and Supports (MLTSS)

In many states, Long-Term Care Medicaid is not paid directly by the state to each provider. Instead, the state contracts with managed care organizations (health plans) that arrange and pay for long-term care, and often medical care too, for their members. This approach is called managed long-term services and supports (MLTSS). If you live in an MLTSS state, your health plan will play a big role in what care you get and from whom. This guide explains how MLTSS works, what changes for members, and how to make it work well.

Figures change periodically. Double-check current amounts before relying on them.

The short version

In MLTSS, the state pays a health plan a fixed monthly amount per member, and the plan is responsible for arranging covered long-term services and supports, such as nursing home care, personal care, adult day care and other home and community-based services.
Many states have adopted MLTSS, and the number has grown over time. Each state designs its own program.
Members usually choose a plan from two or more options, or are assigned one if they do not choose.
Each member gets a care coordinator or care manager who helps plan services.
Members must generally use the plan’s provider network, and many services need prior authorization.
Members keep the right to appeal plan decisions, first to the plan and then through a state fair hearing.
Financial eligibility is still decided by the state Medicaid agency, not the plan.

How MLTSS works

The basic model

The state decides who must or may enroll (for example, older adults and adults with physical disabilities who need long-term care).
The state contracts with health plans and pays them a monthly “capitation” rate per member.
Each plan builds a network of providers: nursing homes, home care agencies, adult day programs, assisted living facilities and others.
The plan assesses each member’s needs, develops a care plan, authorizes services and pays providers.
The state monitors plans for quality, access and compliance.

Federal authorities

States run MLTSS under section 1115 demonstrations, combined section 1915(b) and 1915(c) waivers, or other authorities. Federal managed care rules (42 CFR Part 438) set standards for networks, care coordination, member rights, appeals and quality.

What changes for members

Choosing a plan

Members usually choose among plans. Things to compare:

whether current providers (doctors, home care agency, nursing home) are in the network;
care coordination approach;
extra benefits;
member satisfaction and quality ratings, if published;
customer service.

Care coordination

Each member has a care coordinator who:

conducts assessments;
develops a person-centered service plan;
authorizes services;
helps coordinate with doctors, hospitals and family;
reassesses as needs change.

A good care coordinator can be a valuable ally. Families should get the coordinator’s direct contact information.

Networks and authorizations

Members generally must use network providers. Services such as personal care hours, adult day care or equipment usually need authorization. If a plan reduces or denies services, it must send written notice explaining the decision and appeal rights.

Continuity of care

When a person first enrolls, states usually require plans to continue existing services and providers for a transition period, so care is not disrupted.

Medicare and MLTSS

Many MLTSS members also have Medicare. Some states offer integrated plans that cover both Medicare and Medicaid benefits through one organization, often as Dual Eligible Special Needs Plans (D-SNPs) with aligned enrollment. Integrated plans can simplify care, with one card, one care coordinator and one set of rules. See Dual eligibility.

Appeals and grievances

Federal rules give members strong rights:

Notice. The plan must send a written notice of any denial, reduction, suspension or termination of services.
Plan appeal. The member can ask the plan to reconsider, usually within 60 days of the notice. The plan must decide standard appeals within 30 days, or 72 hours for expedited appeals when health is at risk.
Continuation of benefits. If the member appeals a reduction or termination within the required time (generally within 10 days of the notice or before the effective date), services can continue during the appeal.
State fair hearing. If the plan upholds its decision, the member can request a state fair hearing.
Grievances. Members can file complaints about quality, customer service or other concerns.

See Fair hearings and appeals.

Ombudsman programs

Many MLTSS states have an ombudsman program specifically for managed care members, in addition to the long-term care ombudsman for facility residents. These programs help members understand their rights and resolve problems with plans.

Advantages and concerns

Possible advantages

One organization coordinating care.
A care coordinator to help navigate services.
Flexibility for plans to offer services beyond the minimum.
Emphasis on home and community care.

Common concerns

Network limits may mean changing providers.
Authorization processes can delay services.
Plans may reduce hours, requiring appeals.
Complexity for members and families.

A simple example

Eleanor, 81, lives in an MLTSS state and qualifies for Long-Term Care Medicaid. She chooses a plan that includes her long-time home care agency. Her care coordinator visits, assesses her needs and approves 25 hours a week of personal care and adult day care twice a week. A year later, after a reassessment, the plan sends a notice reducing her hours to 15. Eleanor’s daughter files an appeal within 10 days, so services continue at 25 hours during the appeal. The daughter submits a letter from Eleanor’s doctor describing her recent falls. The plan reverses its decision.

Preparing for the assessment and care plan meeting

Plans decide hours and services largely from the assessment, so preparation matters:

keep a diary of the help needed each day and night for a week or two;
list falls, emergency room visits and hospital stays in the past year;
bring a medication list and the names of all doctors;
invite the family caregiver to explain what they do and what they cannot do;
ask the coordinator to explain how the hours were calculated;
get a copy of the assessment and the service plan.

If the plan seems wrong, raise it with the coordinator first. If that does not resolve it, use the appeal process.

A note on plan changes each year

Plans can change their networks, extra benefits and procedures. Each year, review the plan’s notices, confirm that key providers are still in the network, and consider switching if another plan would serve the person better.

How MLTSS fits with other programs

A member may also receive Medicare, VA benefits or private long-term care insurance. Coordination matters: the care coordinator should know about every source of care so services are not duplicated and gaps are filled. Families should tell the coordinator about any hospice election, private aides or VA services.

Nursing home residents in MLTSS

In many MLTSS states, nursing home residents are also enrolled in a plan. The plan pays the nursing home, and the resident still pays their patient liability from income. The plan’s care coordinator may visit periodically and can help if the resident wants to return to the community. Families should know who the coordinator is and include them in care plan meetings when helpful.

Self-direction in managed care

Many MLTSS programs must offer a self-directed option, which lets the member hire and manage their own caregivers, including relatives in many states. Ask the care coordinator how self-direction works in the plan, which fiscal agent handles payroll, and whether the plan has a list of available workers.

Key terms

Capitation: a fixed monthly payment per member.
Network: the providers a plan contracts with.
Prior authorization: plan approval required before a service is provided.
Care coordinator: the plan staff member who manages a member’s care plan.
Continuation of benefits: keeping services in place during a timely appeal.

Common mistakes

Not checking whether current providers are in a plan’s network before choosing.
Missing the deadline to appeal and keep services in place.
Not keeping copies of notices and service plans.
Not asking for the care coordinator’s direct contact information.
Assuming the plan decides financial eligibility; the state agency does.

Getting help

The state’s managed care ombudsman or enrollment broker can explain plan choices. The long-term care ombudsman helps facility residents. A Certified Medicaid Planner can help with the financial eligibility application, which comes before plan enrollment.

Frequently asked questions

Can I switch plans? Usually yes, during set periods or for good cause. The state’s enrollment broker handles plan changes.

Does the plan decide whether I qualify for Medicaid? No. The state Medicaid agency decides financial eligibility. The plan decides which services you receive.

Can my family member still be my paid caregiver? Many MLTSS programs offer self-direction. Ask your plan.

What if my nursing home is not in the plan’s network? Plans usually must allow existing residents to stay for a transition period, and many states require broader protections for nursing home residents.

Last updated for 2026. General information only, not legal or financial advice. Medicaid Answers is a free educational resource published by Medicaid Answers Foundation.