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MLTSS 101: What Managed Long Term Services and Supports Really Means for Consumers, States, and Providers
Managed Long Term Services and Supports (MLTSS) is how many states deliver Medicaid LTSS through managed care to expand HCBS, improve coordination, and strengthen accountability.
March 12, 2025 – As Medicaid programs face rising demand for long-term services and supports, more states have turned to Managed Long Term Services and Supports (MLTSS) as a way to bring greater coordination, accountability, and consistency to LTSS delivery. However, “MLTSS” is often used as a catch-all phrase, even though the reality is more nuanced. States structure these programs differently, cover different populations, carve services in and out, and set very different expectations for plans and providers.
With MLTSS becoming an increasingly important field with the aging population, it’s an important topic to explore in detail. In the blogs that follow, we will take a deeper look at how states design MLTSS, who their programs are built to serve, and what it looks like when states move from basic oversight to true outcomes-driven payment in LTSS. This first blog is a practical primer on what MLTSS is, how it evolved, what it typically covers, and why it matters for consumers.
Quick History of MLTSS
Long-term services and supports are the hands-on services that help people live safely when they need assistance with daily life because of age, disability, or chronic conditions. Medicaid is the primary payer for LTSS nationally, covering services in settings that range from nursing facilities to home and community-based services (HCBS).
For decades, many Medicaid LTSS systems were built around fee-for-service payment, fragmented service delivery, and institutional care as the default. Over time, states began using managed care as a strategy to coordinate services for people with complex needs and high costs. Managed Long Term Services and Supports (MLTSS) is the version of that strategy focused specifically on LTSS, where states contract with managed care plans to deliver or manage services.
The shift has been substantial. MACPAC notes that the number of states operating MLTSS programs grew significantly from the mid-2000s into the 2010s and beyond, reflecting how central MLTSS has become to Medicaid program design.
However, it is important to remember that MLTSS is not a single standardized national program. It is a policy framework that states implement in very different ways. Some states carve most LTSS into managed care, others carve in only certain populations or services, while others combine MLTSS with Medicare-Medicaid integration strategies for dual-eligible individuals. That variation is one reason MLTSS can feel confusing from the outside, even though it affects millions of lives and billions in spending.
The Benefits and Importance of MLTSS
MLTSS is often framed as a way to get three things Medicaid LTSS systems struggle with when they rely only on fee-for-service: coordination, consistency, and accountability.
The first benefit of MLTSS, is better care coordination for people with complex needs. LTSS users often interact with multiple systems at once, including primary care, hospitals, behavioral health, pharmacy, housing supports, caregiver networks, and LTSS providers. When those systems do not communicate, consumers experience avoidable crises, caregiver burnout, and unnecessary institutional placement. MLTSS is designed to create one entity that is responsible for coordinating services and transitions, instead of leaving consumers and families to stitch everything together themselves.
MLTSS also allows for HCBS expansion and community inclusion. This matters because for many consumers, “better care” is not just a clinical outcome. It is the ability to live at home, stay connected to community, and avoid preventable institutionalization. HCBS policy exists to support those goals, and MLTSS is one of the major vehicles states use to operationalize them at scale.
Finally, MLTSS provides more leverage to enforce quality and access. In fee-for-service LTSS, states can set rates and write provider requirements, but they often have fewer tools to ensure performance across broad provider networks. In MLTSS, the contract provides leverage because states can require network adequacy, timeliness of assessments and service start, care management standards, and performance improvement expectations, then monitor compliance through encounter data and quality oversight. With payment tied to performance, providers and plans need to deliver what matters to consumers, instead of just caring about the volume of services provided and their bottom line.
VBP and MLTSS
If MLTSS is the “delivery and accountability” framework, value-based payment (VBP) is the payment strategy that many states use to push MLTSS beyond administration and into measurable improvement.
VBP in MLTSS can take a few different forms. The first is state-to-plan incentives. States can embed value-based purchasing into managed care procurement, contracting, and oversight. One common tool is a withhold arrangement, where the state holds back a portion of capitation payments and returns them only if the managed care plan meets performance targets. CMS’s Innovation Accelerator Program describes how VBP withholds can be tied to progress such as increasing the share of payments under VBP arrangements or increasing the share of provider contracts incorporating VBP approaches.
The next is plan-to-provider payment models, which leads to the question of what happens downstream in LTSS markets. Does the plan simply report quality, or does it actually change how it pays HCBS providers, nursing facilities, and other LTSS organizations? This is where MLTSS-specific measurement matters. CMS publishes technical specifications for LTSS quality measures, reflecting efforts to measure what matters in LTSS delivery rather than relying only on general medical quality measures.
When states and plans use these kinds of LTSS-relevant measures, VBP can move from abstract “value” language into concrete accountability tied to outcomes such as service access, community tenure, and experience.
The big takeaway is that VBP in MLTSS is not automatically a win. If the incentives are small, the measures are misaligned, risk adjustment is not properly managed, or the provider market is fragile, VBP can become a reporting exercise rather than a transformation strategy. But when states design VBP tools that reflect LTSS realities, MLTSS becomes a structure that can reward keeping people safely supported at home, improving continuity, and strengthening consumer experience.
Advocate’s Perspective
MLTSS is an important policy lever because it sits at the intersection of financing, daily lived experience, and system accountability. For consumers, the promise of MLTSS is not just “care coordination” as a concept. It is getting services started on time, having a stable care team, avoiding unnecessary institutional placement, and being treated as a whole person with goals that extend beyond medical visits. It’s important to note that the VBP conversation inside MLTSS also matters. When incentives and measures are designed well, they can push managed care plans to invest in the supports that actually keep people safe and stable in the community, rather than defaulting to utilization management alone.
Onward!
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About the Author
Fady Sahhar brings over 30 years of senior management experience working with major multinational companies including Sara Lee, Mobil Oil, Tenneco Packaging, Pactiv, Progressive Insurance, Transitions Optical, PPG Industries and Essilor (France).
His corporate responsibilities included new product development, strategic planning, marketing management, and global sales. He has developed a number of global communications networks, launched products in over 45 countries, and managed a number of branded patented products.
About the Co-Author
Mandy Sahhar provides experience in digital marketing, event management, and business development. Her background has allowed her to get in on the ground floor of marketing efforts including website design, content marketing, and trade show planning. Through her modern approach, she focuses on bringing businesses into the new digital age of marketing through unique approaches and focused content creation. With a passion for communications, she can bring a fresh perspective to an ever-changing industry. Mandy has an MBA with a marketing concentration from Canisius College.
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