Most people enter the long-term services and supports (LTSS) system during a crisis that is often preceded by an acute health care episode. When this happens, those in need of LTSS are often surprised to learn that Medicare and private insurance coverage do not pay for these services. As a result, many people pay out of pocket for LTSS, and at some point they “spend down” their income and assets on services and qualify for Medicaid.

This strategy describes different approaches and implementation mechanisms that states have used to expand access to limited home- and community-based services (HCBS) benefits for “pre-Medicaid” at-risk individuals, along with program case studies:


  • Expanding access to a limited set of HCBS for people who would not otherwise qualify for Medicaid to slow their likely future need for more expensive Medicaid LTSS

 Implementation Mechanisms

  • Section 1115 waiver
  • State general funds

State Case Studies

  • Expanding access to services for individuals at-risk of needing LTSS (WA)
  • Expanding HCBS to people at-risk of needing intensive LTSS (VT)