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Who Is MLTSS Designed For? Understanding the Populations States Prioritize in Managed LTSS
MLTSS is not built for just one Medicaid population. This overview looks at the major groups states target through MLTSS and related managed care models, and why those design choices shape access, coordination, and payment reform.
April 24, 2025 –
In the first blog of this series, we looked at managed long-term services and supports (MLTSS) as a Medicaid strategy for coordinating long-term services and supports (LTSS). We also explored how states use MLTSS to improve accountability, expand home and community-based services, and create stronger connections across fragmented systems of care. That foundation matters because once a state decides to use MLTSS, the next question becomes just as important: who is the program actually built to serve?
The answer is not the same everywhere. Some states focus MLTSS primarily on older adults and people with physical disabilities. Others design their programs around dual-eligible members who need better Medicare-Medicaid coordination. Some states also use managed care structures for populations with intellectual and developmental disabilities (IDD) or significant behavioral health needs. Understanding those target populations is essential because it shapes everything from benefit design and network requirements to care management expectations and value-based payment strategy.
Population 1: Older Adults and People With Physical Disabilities
One of the most common uses of MLTSS is to serve older adults and adults with physical disabilities who need help with daily living over a long period of time. These are often the populations most closely associated with traditional long-term services and supports because they are the groups most likely to need personal care, attendant services, nursing facility care, adult day services, home modifications, and other supports that make community living possible.
Florida is a useful example when examining MLTSS in this context. Its Statewide Medicaid Managed Care Long-term Care program is built around individuals who need nursing facility level of care and long-term supports, with a strong emphasis on coordinating services in the community where possible. That makes Florida a good illustration of how MLTSS is often designed to support older adults and adults with disabilities who need sustained, hands-on assistance rather than short-term clinical treatment alone.
Pennsylvania also demonstrates this population focus through Community HealthChoices. While 90% of the CHC eligible are dual-eligible, it also serves older adults and adults with physical disabilities who need LTSS. This is important because it shows how states do not always separate populations into neat boxes. In practice, a single MLTSS program may serve both traditional LTSS users and individuals whose care needs are shaped by both Medicare and Medicaid.
New York’s Managed Long Term Care (MLTC) program is another major example. MLTC is designed for people who need community-based long-term care services for more than a short period, and it has become one of the most visible MLTSS models in the country. New York helps illustrate how states may use MLTSS not only to finance LTSS through managed care, but also to support a broader rebalancing strategy that encourages community-based services over institutional care whenever possible.
This population matters because older adults and people with physical disabilities are often navigating multiple systems at once. They may need help with bathing, dressing, meals, transportation, medication management, durable medical equipment, and coordination with hospitals or primary care providers. Without a strong care management structure, it is easy for these services to become fragmented. MLTSS is intended to reduce that fragmentation and make the system more navigable for people who rely on it every day.
Population 2: Dual-Eligible Emphasis
Another major MLTSS design approach focuses on people who are eligible for both Medicare and Medicaid. These dual-eligible members often have some of the most complex care needs in the system because their services are split across two large public programs. Medicare may cover their acute care, physician services, and prescription drugs, while Medicaid may cover LTSS , medical services not covered by Medicare, and other wraparound supports. When those financing streams are not aligned, the burden of coordination often falls on the individual and their family, which can lead to less than optimal services as consumers and their families find the system difficult to maneuver.
As discussed in the section above, Pennsylvania’s Community HealthChoices is a strong example of this dual-eligible emphasis. This program brings LTSS and physical health services into a managed care framework while also aiming to better coordinate with Medicare coverage for members who qualify for both programs. This makes Pennsylvania an important case study for understanding how MLTSS can be designed not just around service delivery, but around system alignment.
Minnesota Senior Health Options, or MSHO, is another key example. Minnesota has long been viewed as a leader in integrated care for older adults who are dual eligible, and MSHO is a model that tries to reduce fragmentation between Medicare and Medicaid. In this type of design, the state is not simply asking managed care organizations to administer benefits. It asks them to help bridge a longstanding divide between healthcare and long-term services.
The dual-eligible population is especially important in MLTSS because these individuals are more likely to have overlapping medical, functional, and social support needs. They may cycle between hospitals, rehabilitation settings, primary care, behavioral health providers, and home-based LTSS. If those transitions are not managed well, the result can be avoidable hospitalizations, poor member experience, and higher long-term costs. That is why dual-focused MLTSS models tend to place such a heavy emphasis on coordination, interdisciplinary care planning, and member navigation.
Population 3: IDD and Behavioral Health Needs
MLTSS and related managed care strategies are not limited to older adults or dual-eligible populations. Some states also use managed care models for individuals with intellectual and developmental disabilities (IDD), behavioral health needs, or both. These programs can look very different from traditional MLTSS because the service package, provider network, and quality priorities are often shaped by habilitation, crisis supports, community integration, and long-term functional outcomes rather than aging-related care needs alone.
Tennessee’s Employment and Community First CHOICES (ECF CHOICES) is one of the clearest current examples of a managed LTSS program designed specifically for people with intellectual and developmental disabilities. ECF CHOICES is a program administered by TennCare through its contracted managed care organizations, offering services for people of all ages with IDD to support employment and independent community living. That makes it especially useful in an MLTSS discussion because it shows how a state can build a specialized managed care pathway around long-term functional supports rather than an aging-focused LTSS model.
North Carolina’s Behavioral Health IDD Tailored Plans are another current example of a specialized managed care model built for people with significant behavioral health needs, intellectual and developmental disabilities, and traumatic brain injuries. The state launched the Tailored Plans on July 1, 2024, with these plans described as fully integrated managed care plans that cover physical health, behavioral health, IDD, TBI, LTSS, pharmacy, and unmet health-related resource needs. This makes them especially relevant to an MLTSS discussion even though they are not a traditional aging-focused MLTSS model. These plans members a single designated care manager supported by a care team to coordinate physical health, behavioral health, LTSS, and social needs. The plans are expected to achieve NCQA LTSS Distinction by the end of Contract Year 3 in 2027.
This category matters because people with IDD or serious behavioral health needs often require long-term, person-centered supports that do not fit neatly into a medical model. Stability, community participation, crisis prevention, family support, supported employment, and functional independence may matter just as much as clinical care. If a state is serious about designing managed care for these populations, it has to think differently about provider networks, quality measures, and what success actually looks like.
Why Population Design Matters
At first glance, these population categories may seem like an administrative detail. In reality, they shape the entire program. A model built for older adults with physical disabilities may focus heavily on attendant care, nursing facility diversion, and caregiver support. A dual-eligible model may place more emphasis on Medicare-Medicaid alignment, transitions of care, and avoidable hospital use. A program built around IDD or behavioral health needs may prioritize habilitation, crisis stabilization, and community participation.
This is also where value-based payment becomes more complicated. States cannot simply apply one generic VBP model across every MLTSS population and expect it to work. The measures, incentives, and outcomes must reflect the needs of the people being served. Community tenure may be especially important for older adults. Care transitions and hospitalization rates may matter more in dual-eligible models. Stability, independence, and continuity of community-based supports may be more meaningful for people with IDD or serious behavioral health needs.
Asking who MLTSS is designed for tells us what a state is prioritizing, what outcomes it values, and what kind of accountability it is trying to create.
Advocate’s Perspective
When policymakers talk about MLTSS, it can be tempting to treat it as a single category of Medicaid reform. But the populations inside these programs have very different needs, risks, and goals. That is why population design matters so much. It affects whether the program feels person-centered or administrative, whether quality measures are meaningful or performative, and whether value-based payment supports real outcomes or just creates more reporting burden. In the next blog, we will build on this discussion by looking more closely at how states structure MLTSS programs differently, and why those structural choices shape access, oversight, and accountability.
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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