What is Nursing Home Level of Care & Its Importance to Medicaid Eligibility

Last updated: August 13, 2019

 

What is “Nursing Home Level of Care” (NFLOC)?

A “nursing home level of care”, also called a nursing facility level of care and abbreviated as NFLOC, is a measure of care needs that must be met for Medicaid nursing home admissions. This level of care is also frequently used as a criteria for one to receive long-term care services and supports from a home and community based services (HCBS) Medicaid waiver.

The term “nursing home level of care” is not easily definable, as there is no formal federal definition. Instead, each state and the District of Columbia has the task of defining what this means in their own state. Although the rules are not consistent from one state to the next, the following four areas are commonly considered when a state determines a person’s level of care need. Remember, these are generalizations, which means all states likely do not consider all four areas.

Physical Functional Ability
One’s ability (or inability) to complete day to day activities, called activities of daily living (ADLs) are very often taken into account. These are basic activities that a person must complete on a daily basis in order to take care of oneself. These activities include bathing and personal hygiene, putting clothes on and taking them off, using the toilet and cleaning up after oneself, mobility / transferring (walking from one room to another, getting out of bed and into a chair), and eating. In addition, instrumental activities of daily living (IADLs) may also be taken into account. These activities do not necessarily need to be done on a daily basis, but are necessary to live independently. Examples include shopping for groceries and other essentials, meal preparation, housecleaning, laundry, medication management, and paying the bills.

Health Issues / Medical Needs
One’s health, or medical needs, are also frequently considered when determining if a senior meets a nursing home level of care. Examples includes needing assistance with injections, catheter care, and intravenous (put into a vein) medications.

Cognitive Impairment
Cognitive (mental) functioning may also be considered when determining if a senior meets a NFLOC. This area is particularly relevant for persons who have Alzheimer’s disease or a related dementia, such as dementia from Parkinson’s disease or Lewy body dementia. If a senior’s judgement is impaired, he / she may not be able to make appropriate and / or safe decisions, putting himself / herself in danger if living independently without supervision and assistance.

Behavioral Problems
Behavioral issues, also commonly seen in persons with dementia, particularly in the mid-late stage of the disease, may also be taken into account when determining if an individual meets a nursing home level of care. Examples of such behaviors may be frequent wandering from the home and becoming lost, impulsiveness, and aggressiveness (physical, sexual, verbal).

 

 

How is NFLOC Determined?

States use functional assessment tools in order to determine if a person meets a nursing facility level of care.

These tools generally consist of a compiled list of questions (usually on paper, but sometimes in a database). The most common functional consideration is one’s ability / inability to perform one’s activities of daily living (bathing, dressing, grooming, etc.). The questions may ask how often (how many times each day / how many days each week), for how long (how many minutes), and what type of assistance (verbal cues, assistive devices / adaptive equipment, hands on assistance, 100% dependent) a person requires. Questions regarding one’s health, mental functioning, behavior, and family support may also be included. With these questionnaires, a state may set a minimum score (a threshold number) and if the candidate reaches that score, it indicates he / she meets the LOC need. For instance, the requirement of verbal ques to perform an activity might earn 1 point, the physical need for assistance might earn 2 points, troubling behavior such as wandering might earn 3 points, and the need to be constantly supervised to ensure safety might also earn 3 points. Other states may set a minimum number of ADLs in which a senior requires assistance, and if he / she cannot perform the minimum number of ADLs set forth, he / she meets the nursing home level of care requirement. Some states may consider needing assistance with 2 ADLs as sufficient to be labeled as requiring a NFLOC, while other states may require assistance with 4 ADLs. Still, other states set forth specific definitions and rules and the person completing the LOC assessment uses them as a guideline. Regardless of how the state makes its determination, most states look at a combination of factors, as mentioned above.

In addition, some states may require a physician diagnosis of specific medical conditions or a statement that the Medicaid applicant requires the level of care provided in a nursing home.

 

 Being assessed as requiring Nursing Facility Level of Care in one state does not mean one will automatically receive the same assessment in any other state.

 

As with the definition of NFLOC, the federal government does not require states to use a specific assessment tool. This means that a large number of functional assessment tools exist nationwide. In fact, according to MACPAC, more than 120 tools are used, some of which are state-developed. Therefore, there is no consistency between states as to how this determination is made, and because of this, a senior may meet a nursing home level of care in one state, but not another state.

 

Why is it Important to Medicaid Eligibility?

One’s level of care need is crucial to being eligible for nursing home Medicaid, as the program will not pay for nursing home care if an applicant does not require a level of care that is consistent to that which is provided in skilled nursing facilities.

This is significant in that many families are in the position that their loved one requires more care than they can provide at home, but they do not require a high enough level of care to be admitted to a nursing home. The in-between level of care is typically provided in assisted living. However, assisted living is only covered by Medicaid in a very limited capacity.

Many Medicaid waivers use nursing home level of care as a criteria to receive long-term services and supports in the home and community, which may include home care, adult day care and adult foster care. (Remember, Medicaid also has income and asset requirements as well. State specific eligibility information can be found here).

Again, Medicaid determination of a nursing home level of care in one state does not mean that the same individual will meet this level of care in another state. For instance, say an elderly individual is currently receiving long-term care Medicaid in California, but wishes to relocate to Florida. It cannot automatically be assumed that the senior will meet the NFLOC in the Florida.

 

Who Determines Nursing Home Level of Care?

The person or agency who completes the functional assessment and makes the determination of a NFLOC also varies based on the state in which one resides. Often, it is persons employed by the state or local Medicaid agency that make this determination. However, one’s local Area Agency on Aging (AAA) office, local Aging and Disability Resource Center (ADRC), or another agency (contracted by Medicaid) may be tasked with determining a Medicaid applicant’s level of care need.

These functional needs assessments are usually done in person, often in the home of the senior.

Who Pays for the Determination?

Since the functional assessment to determine level of care need is part of the Medicaid application process, Medicaid pays for the assessment. Said differently, the person who is in need of long-term care Medicaid does not pay for the assessment.

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