Abstract
IMPORTANCE: Managed Long-Term Services and Supports (MLTSS) has been implemented by more than half of all state Medicaid programs, but knowledge of its scope and consequences for caregiving is limited. OBJECTIVE: To describe observed trends in MLTSS program presence and care hours among older adults dually enrolled in Medicare and Medicaid between 2012 and 2022. DESIGN, SETTING, AND PARTICIPANTS: This repeated cross-sectional study used data from the 2012-2022 National Health and Aging Trends Study (NHATS) linked with county-level measures of MLTSS program presence. Included in the study were adults aged 70 years or older dually enrolled in Medicare and Medicaid (hereafter older dual enrollees) who were living in the community and receiving assistance with self-care or mobility activities. Data analyses were conducted from December 2023 to June 2025. EXPOSURE: Residence in an area with MLTSS program presence. MAIN OUTCOMES AND MEASURES: The primary outcome was the total care hours per week received by older dual enrollees estimated as the mean (SD) care hours received per week overall and by caregiver type for each survey round. Percentages were weighted to account for the complex survey design. RESULTS: Among 2549 participants, the mean (SD) age was 80.3 (8.5) years, 70.1% were female, and 26.5% lived alone. The weighted percentage of community-living, older dual enrollees receiving assistance who resided in areas with an MLTSS program increased from 39.4% in 2012 to 71.4% in 2022. Older dual enrollees receiving assistance were helped by a mean (SD) of 2.8 (1.6) caregivers and received 65.6 care hours per week (weighted percentage of total care hours, 80.9%). Fifty percent of participants received paid help. Most care hours were provided by unpaid family caregivers (mean [SD] care hours per week, 42.0 [74.0]). Mean (SD) weekly care hours for those residing in areas with continuous MLTSS presence were higher than those living in areas that added or had no MLTSS program presence (72.9 [82.8] vs 61.6 [71.7] and 60.0 [85.0] hours, respectively; P = .03). Among those residing in areas with continuous MLTSS, mean (SD) care hours provided by paid family caregivers increased steadily over the observation period from 2.0 (11.0) hours in 2012 to 23.8 (57.9) hours in 2022. CONCLUSIONS AND RELEVANCE: This cross-sectional study found increases in the percentage of older dual enrollees receiving assistance in the community and residing in areas with MLTSS program presence, with persistent heavy reliance on unpaid family caregivers. Systems are needed to monitor the care experiences of patients and their caregivers.