If Medicaid moves your parent's care into managed long-term services and supports (MLTSS), a health plan approves services and hears the first appeal, but the state decides who qualifies. The state pays the plan a fixed amount per member.

In This Guide

What Changes Under Medicaid MLTSS, and What Doesn't

CMS defines MLTSS as the delivery of long-term services and supports through capitated Medicaid managed care programs. "Capitated" means the plan, such as a managed care organization (MCO), gets a set amount per member whether or not that member uses services. Federal rules define an MCO as an entity that has, or is seeking, a comprehensive risk contract. It must have written policies for selecting and keeping network providers, and it pays the providers it contracts with., States set this up under a managed-care authority (1915(a), 1932(a), 1915(b) or a Section 1115 demonstration) paired with a home-care authority such as a 1915(c) waiver.

As one state's example of what MLTSS covers, New Jersey's Medicaid agency says its program includes all NJ FamilyCare Plan A benefits, care management, home and vehicle modifications, home-delivered meals, respite, personal emergency response systems, mental health and addiction services, assisted living, community residential services and nursing home care.

What changes:

What stays the same:

  • Who decides eligibility. Under 42 CFR 431.10, the state Medicaid agency, or a merit-system government agency it delegates to, determines eligibility and runs fair hearings. CMS's 2013 guidance for Section 1115 and 1915(b) MLTSS programs says plans shouldn't take part in eligibility or functional assessments before someone enrolls. That bar covers the time before enrollment; afterward, a plan's assessment can matter too. In New Jersey, for example, when a plan member finishes short-term nursing-home rehabilitation, the plan conducts the MLTSS clinical assessment and the state's Division of Aging Services determines clinical eligibility.
  • The benefit floor. MLTSS plan services must be no less in amount, duration and scope than fee-for-service Medicaid provides.

MLTSS vs. Fee-for-Service Medicaid

In fee-for-service Medicaid, states can offer home care through 1915(c) waivers for people who would otherwise need the level of care a hospital or nursing facility provides.

MLTSS Fee-for-service
Who pays providers The plan, which the state pays per member (capitation) The state Medicaid agency
Who decides eligibility The state agency, not the plan The state agency
Standard approval deadline 7 calendar days for rating periods from Jan. 1, 2026 (states may set shorter; extendable up to 14 days) 7 calendar days for non-drug items and services from Jan. 1, 2026 (state law may set shorter; extendable up to 14 days)
Benefit floor No less than fee-for-service Each service sufficient to achieve its purpose
If denied Plan appeal, then state fair hearing (aligned dual plans differ) State fair hearing

Sources: 42 CFR 438.2, 438.106 and 438.210 (plans), 42 CFR 440.230 and 447.10 (fee-for-service) and 42 CFR 431.220 (hearings).,,,,,

Which States Have MLTSS?

On its MLTSS page, published March 2022, the Medicaid and CHIP Payment and Access Commission (MACPAC) counted 24 states with MLTSS programs as of 2021. That count is dated, so ask your state Medicaid agency whether it runs MLTSS and who must enroll. Brevy has guides to MLTSS in New Jersey, Pennsylvania, New York, Tennessee and Texas, plus how Georgia delivers long-term care. Otherwise, start with HCBS waivers by state.

The Program of All-Inclusive Care for the Elderly (PACE) is a separate option for people 55 or older who live in a PACE organization's service area, whom the state finds need nursing-home-level care, and who can live safely in the community when they enroll.

Choosing a Plan and Keeping Your Providers

Worried about losing a trusted aide?

  • Neutral help choosing. CMS's 2013 guidance for Section 1115 and 1915(b) MLTSS programs says choice counseling must come from an entity that isn't a plan, a provider or an entity that makes eligibility decisions. Auto-assignment should happen only if you don't choose, and should weigh your current long-term care providers. That guidance isn't a regulation, and it predates the 2024 managed care rules.
  • Transition of care. Your state's Medicaid managed care transition policy must let an enrollee at risk of serious harm to their health, hospitalization or institutionalization keep a current out-of-network provider "for a period of time." Federal rules set no day count, so ask your state Medicaid agency for its policy.
  • Out-of-network care. If a Medicaid plan's network can't provide a covered service you need, the plan must cover it out of network at no extra cost.
  • Changing plans. Where a state limits switching, you can still ask to leave a Medicaid MLTSS plan without a reason in the first 90 days, at least every 12 months after, and for cause anytime. One MLTSS-specific cause: your residential, institutional or employment-support provider left the plan's network, and changing providers would disrupt where you live or work. A request not decided in time counts as approved.

If the Plan Cuts or Denies a Service

  1. Written notice. The plan must explain its decision, your appeal rights and how to keep benefits meanwhile.
  2. The plan's clock. For rating periods starting on or after January 1, 2026, Medicaid managed care plans must make standard service-authorization decisions within 7 calendar days and urgent ones within 72 hours. A Medicaid managed care plan can extend either deadline by up to 14 days if you ask, or if the plan shows it needs more information and the extension is in your interest.
  3. Plan appeal. File a Medicaid managed care plan appeal within 60 calendar days of the notice date, orally or in writing. Your state sets the plan's deadline to decide, but federal rules cap it at 30 calendar days from when the plan receives a standard appeal and 72 hours for an expedited one, extendable by up to 14 days. If the plan misses its notice and timing rules, you can go straight to a state fair hearing.
  4. State fair hearing. If the plan upholds its decision, you get 90 to 120 calendar days (your state picks) from the plan's appeal decision notice to request a state Medicaid fair hearing.,

A second, shorter clock decides whether services continue. When you appeal a cut, suspension or end of a previously authorized service, a Medicaid managed care plan must keep it going only if all of these hold: you filed the plan appeal on time, an authorized provider ordered the service, the period of the original authorization hasn't expired, and you request continuation within 10 calendar days after the plan's notice (or by the change's effective date, if later). After a losing Medicaid managed care plan appeal, request the state fair hearing and continuation of benefits within 10 calendar days after the plan sends its appeal decision. If you lose, the plan may recover those services' cost under state policy.

More: how to appeal a Medicaid denial, keeping coverage during an appeal and when a plan stops paying the nursing home. In an applicable integrated plan (aligned Medicare and Medicaid coverage), Medicare Advantage (Part C) rules at 42 CFR 422.629 to 422.634 replace these timelines; see integrated dual plans.

Medicaid managed care enrollees can't be held liable for the plan's debts if it goes insolvent, or for covered services the state or plan doesn't pay for.

Can You Self-Direct Care Inside a Plan?

Not always. CMS's 2013 guidance for Section 1115 and 1915(b) MLTSS programs (guidance, not regulation) expects states offering self-direction in fee-for-service to keep it under MLTSS, and others to consider it. Whether a spouse or other legally responsible relative can be paid depends on the state and the Medicaid program.,

In New Jersey Medicaid, the Personal Preference Program lets NJ FamilyCare members hire workers, including relatives, if they are approved for personal care assistant (PCA) services, need them for at least six months, and can self-direct or have an authorized representative who can act for them.,

Frequently Asked Questions

What is the difference between MLTSS and regular Medicaid?

In regular fee-for-service Medicaid, the state pays providers directly. Under MLTSS, the state pays a capitated plan that approves services, runs the provider network and hears the first appeal.,,,,

Does MLTSS change Medicaid eligibility?

No. The plan doesn't get the eligibility decision: the state Medicaid agency, or a merit-system government agency it delegates to, still decides who qualifies, and plan enrollees keep their right to a state fair hearing.,

Can a state make MLTSS enrollment mandatory?

Sometimes. Under the Section 1932(a) state-plan option, a state can require Medicaid enrollees to join a managed care plan, but not people who are eligible for Medicare. States can also run MLTSS through 1915(b) waivers or Section 1115 demonstrations, so your state Medicaid agency can tell you whether enrollment is required in your program.

Can someone else file a Medicaid plan appeal for my parent?

Yes, if state law permits and your parent consents in writing, an authorized representative or provider can file a Medicaid managed care plan appeal on your parent's behalf. A provider can't request continuation of benefits during the appeal.

Learn More

MedicaidWhat Is PACE, the Program of All-Inclusive Care for the ElderlyPACE, the Program of All-Inclusive Care for the Elderly, wraps your Medicare and Medicaid care into one plan. Who qualifies, the real cost, and where it exists. MedicaidWhat Is a Managed Care Organization (MCO)?A Medicaid MCO is a health plan paid a fixed monthly rate to manage a member's care. Here's how MCOs work, who runs them, and how to change yours. CaregiverWhat Are Consumer Directed Services (CDS)?Consumer Directed Services (CDS) lets Medicaid long-term care members hire, train, and manage their own caregivers. Here's how CDS works and who qualifies. MedicaidNew Jersey Medicaid MLTSSNJ Medicaid MLTSS in 2026: how managed long-term care works, who qualifies (age or disability, clinical, financial), the plans that run it, and how to enroll. MedicaidFlorida's SMMC Long-Term Care Waiver: The Complete GuideFlorida LTC waiver in 2026: how the 8-rank frailty waitlist works, the covered home and community-based services, hiring a spouse through PDO, and how to apply. MedicaidHow to Appeal a Medicaid Denial: Your Fair Hearing RightsDenied Medicaid? You can appeal, and one deadline decides whether your benefits keep flowing during the appeal. Know your fair-hearing rights and act fast.

Find personalized help choosing an MLTSS plan or contesting cut hours at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.

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