Short answer: Mostly out-of-pocket spending, Medicaid, and private options, not regular health insurance. Medicaid pays the largest share nationally, but only after you meet income and asset limits.
The Administration for Community Living notes that Medicaid does pay for the largest share of long-term care services, though you must have income and assets below your state’s limits and meet a needs test to qualify. Medicaid.gov confirms it is the primary payer across the nation for long-term care services. Medicare and standard health plans cover only limited skilled care, so they fill little of the gap.
Before someone qualifies for Medicaid, costs usually come out of pocket or from private arrangements such as long-term care insurance, reverse mortgages, certain life insurance options, and annuities. Planning early gives you more of these choices, since long-term care insurance is cheaper and easier to qualify for when you are younger and healthier.