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Facility-Based Care

Guidance for facility-based LTSS, which is provided in institutions such as skilled nursing facilities (also known as nursing homes).


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

Issue Date: June 22, 2016

Facility-based LTSS care is provided in institutions such as skilled nursing facilities (also known as nursing homes). Depending how your state defines facility-based care, such care can also take place in assisted living residences and adult family homes.

Be aware that your state has Medicaid and Medicare requirements for things like how long people can stay in a facility and what kinds of services they can receive there. Medicaid rules vary from state to state, while Medicare requirements are the same across states. The section on eligibility, below, has guidance on finding out more about these requirements.

Get an overview of facility-based LTSS from

There are different facility types included under this LTSS model, and each type may offer different types of services.

Facility and Service Types

Facility Types

  • Skilled nursing facility
  • Nursing home
  • Assisted living residences
  • Adult family homes
  • Some hospice facilities

Service Types

  • Skilled nursing care (not always offered, but required for Medicare licensure)
  • Occupational therapy, physical therapy, and speech therapy
  • Dietary management
  • Hospice and palliative care (not always offered)

Facility-based care provides some benefits and also presents a few challenges. The benefits listed below do not necessarily apply only to this care model. Some of the benefits provided by facility-based care can also be reached using other care models.

Benefits and Challenges of Facility-Based Care


  • 24-hour care
  • Comprehensive care
  • Secure living environment
  • Tribally run facilities may provide culturally competent care
  • If licensed through Medicare, services are open to non-AI/ANs, which can ensure quality care for non-Indian community members and mean more income for your program since more patients are being served


  • High cost to operate, including an initial investment and operating expenses
  • Patient may be separated from family and may need to move far away from family to receive care
  • A minimum occupancy level is necessary for financial viability
  • If licensed through Medicare, services must be open to non-AI/ANs, which may not fit with your original plan or budget
  • Few facilities provide culturally competent care

Does Your Community Need Facility-Based Care?

How do you decide if facility-based care is what your community needs? In addition to weighing the benefits and challenges, look at the results of your needs assessment. If there is a strong need for medical supervision or skilled medical care, you might consider this model. Perhaps you already have a home- and community-based program in place, and a facility-based care model would complement the services you already offer.

Frequently Asked Questions

Who is Eligible for HCBS?

Eligibility varies based on the requirements of the main payers, which include Medicaid and Medicare. You will need to look into:

  • Medicaid requirements, which vary by state. The State Resources Map can help you begin looking into this issue. When you get to the map, click on your state, and then follow the links that deal with Medicaid to find state-specific information on eligibility.
  • Medicare requirements, which are the same for all states. Learn more about what Medicare will cover.

Who Funds Facility-Based Care?

Facility-based care is covered largely by patient-generated revenue or funds that come as payment for providing services to individuals. Medicaid is another major payer for facility-based care.

Medicare does not cover facility-based care if the only care a patient needs is help with activities of daily living, which are non-medical tasks such as bathing, dressing, eating, or using the bathroom. Medicare does cover certain specific types of care, including medical care in a long-term care hospital or skilled nursing care in a skilled nursing facility.



Check out these TA Center Resources to learn more about different types of funding for facility-based care.

Who Operates LTSS Facilities?

An LTSS facility can be operated by a tribe, a nonprofit, or a corporation.

The Tohono O'odham Nation's skilled nursing and hospice care facility is a strong example of a tribally run long-term care facility. Watch this video to learn more about their program. 

Learn More About Facility-Based Care

Individuals may choose to move to a facility because they need certain support services.

Learn more about which services may be provided by different types of facilities.

Explore the State Resources Map for state-specific information that will guide your next steps and help you understand your state's situation and which state agencies you should work with. See accreditation considerations to guide you in deciding what types of training you should plan for and which accreditation agency you will need to work with.

In addition to the facility types listed above, some facilities provide services specially designed for patients who have dementia. Is this a need in your community?


Learn more about strategies that work well for facility-based care in Indian Country by checking out these resources:

Transitional Care

Transitional care works to maintain the quality of care for elders and persons with disabilities when they transition to or from hospital or nursing home facilities and residential or home settings. Transitional care is important as a part of both facility-based care and HCBS.

Learn more about transitional care.

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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.