Despite increasing use of home and community-based services, the organization, financing, and delivery of Medicaid-funded long-term care services remains biased towards institutional care. Recognizing the challenges, the Affordable Care Act contains a number of provisions to help States balance their Medicaid long-term service delivery systems by expanding access to an array of home and community-based services and reducing dependence on institutional care, including:

• A new State Balancing Incentive Payments Program to encourage States to increase Medicaid long-term services and supports (LTSS) in the home and  community
• New Medicaid State Plan options for home and community-based services
• Increased funding for rebalancing initiatives like Money Follows the Person (MFP)

In addition to the Affordable Care Act provisions, there are several grant and program initiatives designed to assist States in balancing and promoting systems change, including:

• Real Choice Systems Change Grant program (RCSC)
• Homelessness Initiatives
• Employment Initiatives

Goals of a Balanced Medicaid Funded Delivery System

The goal of the Medicaid balancing initiatives is to create a person-driven, long-term support system that offers people with disabilities and chronic conditions choice, control and access to services that help them achieve independence, good health and quality of life.

A balanced system is:

• Person-driven:  The system gives people choice over where and with whom they live, control over the services they get and who they get services from, the chance to work and earn money, the option to include friends, and supports to help them participate in community life.
• Inclusive: The system encourages people to live where they want to live, with access to a full array of community services and supports.
• Effective & Accountable: The system offers high quality services that improve quality of life. Accountability and responsibility is shared between public and private partners, and includes personal accountability and planning for long-term care needs, including greater use of private funding sources.
• Sustainable & Efficient: The system efficiently coordinates and manages a package of paid services appropriate for the beneficiary, paid for by the right entity.
• Coordinated & Transparent: The system coordinates services from various funding streams to provide a seamless package of supports, and uses health information technology to effectively provide transparent information to consumers, providers and payers.
• Culturally Competent: The system provides user-friendly, culturally-appropriate, accessible information and services.

National Balancing Indicator Project

The Centers for Medicare & Medicaid Services (CMS) commissioned the National Balancing Indicator Project (NBIP) to develop and test the feasibility of implementing national indicators to assess States’ efforts toward attaining and maintaining a balanced, person-driven long-term supports and services (LTSS) system. The mission of the NBIP is to assist CMS and States in developing indicators that will help gauge a State’s success in “balancing” its long-term support program, which will in turn inform Federal and State policy making.

The NBIP began in FFY 2007 and continues into 2014. Get more information on NBIP.