Long-term services and supports (LTSS) refer to a broad range of health and health-related services and supports needed by individuals who lack the capacity for self-care due to a physical, cognitive, or mental disability or condition. Often the individual's disability or condition results in the need for hands-on assistance or supervision over an extended period of time. Medicaid plays a key role in covering LTSS to aged and disabled individuals. As the largest single payer of LTSS in the United States, federal and state Medicaid spending accounted for $136.3 billion or 42.0% of all LTSS expenditures in 2012 ($324.2 billion). LTSS are also a substantial portion of spending within the Medicaid program relative to the population served, accounting for over one-third (35.3%) of all Medicaid spending. Of the 66 million total enrolled Medicaid population, an estimated 4.2 million (or 6.4%) Medicaid beneficiaries received LTSS in 2011. Medicaid funds LTSS for eligible beneficiaries in both institutional and home and community-based settings, though the portfolio of services offered differs substantially by state. Moreover, states are required to offer certain Medicaid institutional services to eligible beneficiaries, while the majority of Medicaid home and community-based services (HCBS) are optional for states. In recent decades, federal authority has expanded to assist states in increasing and diversifying their Medicaid LTSS coverage to include HCBS. As a result, the share of Medicaid LTSS spending for HCBS has more than doubled, accounting for 18% of Medicaid LTSS spending in 1995 to half (50%) of total Medicaid LTSS spending in 2012. States now have a broad range of coverage options to select from when designing their LTSS programs. In general, Medicaid law provides states with two broad authorities, which either cover certain LTSS as a benefit under the Medicaid state plan or cover home and community-based LTSS through a waiver program which permits states to disregard certain Medicaid requirements in the provision of these services, subject to approval. Given the range of available coverage options, states continue to enhance or expand their LTSS delivery systems to cover additional services or target services to specific populations with a focus on HCBS. In FY2014 and FY2015, the number of states reporting activities to expand HCBS increased to 42 and 47 states, respectively (compared to 26 states in FY2012 and 33 states in FY2013). Most states reported using Section 1915(c) HCBS waiver authority programs or the Section 1915(i) HCBS state plan option to expand their HCBS offerings. The Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) established or extended several Medicaid state plan options and grant activities to enhance or expand states' LTSS delivery systems. In FY2013, 19 states reported having at least one of these activities in effect; 12 states reported implementing at least one of these activities in FY2014; and 15 states reported plans to implement in FY2015.