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LTSS Roadmap Resources

Guidance for the LTSS roadmap planning model, which can guide communities through the planning process to establish long-term services and supports or improve its current program.

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: August 03, 2016

The two main models of LTSS are home- and community-based care and facility-based care. Both models offer opportunities for tribal involvement.

Home and Community Based Services (HCBS)

Individualized care delivered in the home and in community settings.

More about the HCBS model >

  • PACE – Program of All-Inclusive Care for the Elderly: A comprehensive long-term care program for elders through Medicare and Medicaid. For most participants, the care is delivered in the home.
    More about the PACE program >

  • MFP – Money Follows the Person: A program to encourage transitioning out of institutional care and into home/community settings. A special AI/AN program increases funding available for tribal communities.
    More about the MFP program >

Facility-Based Care

Care provided in institutions such as assisted living residences, adult family homes, and nursing homes.

More about the facility-based care model >

Tribal Involvement

Depending on the care model chosen, a Tribe can provide or support different aspects of LTSS care.

See examples of tribal involvement >

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.