What is Nursing Home Level of Care and Why it Matters for Medicaid

Definition: “Nursing Home Level of Care” 

A Nursing Home Level of Care (NHLOC) is a formal level of care designation commonly used to determine if a person is eligible for Medicaid-funded, nursing home care. It is also used to determine if someone is eligible to receive long-term care and support from Medicaid at home.

Unfortunately, there is no consistency across the 50 US states on the definition of NHLOC. All states define NHLOC differently. Furthermore, in addition to the lack of consistency, most states do not provide a simple definition. New Mexico’s definition, for example, is 28 pages long.

Having said that, here we provide a simplified and generalized description that should be sufficient for families to determine if their loved one meets the “nursing home level of care” requirement.

If a person is unable to care for themselves for a sustained period of time and not having assistance would result in them being a danger to themselves, they would likely meet the requirement for Nursing Home Level of Care. Typically, states require individuals to be unable to care for themselves in more than one way. For example, a state might require the person to have a combination of memory issues and mobility issues. The reasons for which a person may be unable to care for themselves can be:

  1. Medical – such as they require assistance with catheters, IV drips, ventilators or other medical devices.
  2. Cognitive – such as memory issues resulting from Alzheimer’s / dementia or an inability to process information
  3. Behavioral – such as an inability to control their actions or moods
  4. Functional – such as an inability to manage activities of daily living like dressing, toileting and eating

 Many Names
Depending on the state, one may hear various terms that mean the same thing as NHLOC. Examples include Nursing Facility (NF) Level of Care (LOC), which may simply be abbreviated as NFLOC, Nursing Facility Clinically Eligible (NFCE), Skilled Nursing Level of Care and Level of Care Determination (LOCD).  

 

How & By Whom is “Nursing Home Level of Care” Determined?

Unfortunately, the process to determine NHLOC and who makes that determination differs for each state. Most states require that an individual have a doctor’s diagnosis. However, that may not be sufficient. For example, a doctor may provide a formal diagnosis of Alzheimer’s, but the individual will also need to be observed perhaps by an Occupational, Behavioral or Physical Therapist or a RN to determine what types of assistance and how much assistance they require. For example, is this individual able to transfer (move from the bed to a chair), bathe, get dressed, use a toilet or prepare and consume food? What type of support system does the individual have? Is the person at risk of falling or at risk of being emotionally or physically abused? Is the individual able to administer his or her own medications?

Some states will also evaluate how much care the individual’s family can provide, taking into consideration work schedules, proximity and other responsibilities. This type of analysis is not conducted by a medical doctor but more likely an administrator or assessor in the state’s Medicaid office. Additional consideration factors include the length of time (in the past) for which the need for care has existed and the projected length of time in the future they will require assistance.

Practically speaking, if one is seeking Medicaid assistance, they should not begin by taking their loved one to a doctor to obtain a Nursing Home Level of Care designation. Instead they should start by contacting their state Medicaid office. The state will likely require that a specific group of doctors, therapists or administrators be used to make the determination and it is unlikely that one’s primary care doctor is included in this group.

One thing that remains consistent across the states is that each state uses some sort of assessment tool(s), which may be web-based, downloaded and printed, or goes through a client-server network. However, the assessments themselves and the various parts of the assessments vary greatly. The way the level of care (LOC) determination is made also varies by state. Some states may rank Level of Care (LOC) by low, medium, and high, while others may use a scoring system where the individual is given a numerical score to indicate LOC need.

 

How “Nursing Home Level of Care” Differs by State

The way a state defines a “nursing home level of care” is very different from one state to another. Below follow examples of several more populous states and how they determine NFLOC for their state. Please note, the information that follows may not be 100% accurate as it is quite common for states to revise their requirements and procedures with great frequency. Furthermore, while a policy may be statewide, local administrators may differ in how they execute the policy.

California

In California, Medicaid is called Medi-Cal, and another name used for nursing homes is Skilled Nursing Facilities (SNF). The elderly individual must be observed, the course of treatment assessed, and a doctor must find there is a need for nursing home care. A senior who has a medical condition, such as a feeding tube or has wounds that require care following surgery, that necessitates around the clock skilled nursing monitoring, might be found to need nursing home placement. The inability to self-administer medications, the inability to feed oneself, the need for substantial help with bathing and dressing, or a mental illness might all also be reasons that a senior would require nursing home care. While Alzheimer’s disease and other related dementias are not specifically mentioned by name as reason for nursing home admission, unpredictable behavior and moods, such as depression and anxiety, and the lack of mental and physical functioning as the disease progresses, it is reasonable to assume mid-late stage Alzheimer’s would meet the requirements for SNF care.

New York

In New York, an elderly individual must have a medical need for nursing home care in order to meet the requirements of nursing home level of care. The ability to perform ADLs is evaluated as part of the deciding factor. For example, is the senior able to eat, bathe, dress, get out of bed, and use the bathroom without assistance? To assist in determining one’s level of care need, a RN must complete an assessment known as the Hospital and Community Patient Review Instrument (H/C PRI). Via this tool, assessments are made based on one’s medical conditions, one’s ability to perform ADLs 60% or more of the time, and one’s behavior during the past week. One’s behavior is also taken into account. For instance, has the senior’s behavior been verbally unpredictable, has the individual been physically aggressive, have behavior been inappropriate, or has the senior been hallucinating? Medications and course of treatment are also factored into the assessment.

Florida

In Florida, Medicaid is also referred to as the Statewide Medicaid Managed Care (SMMC) Program. In this state, the terminology Nursing Facility Level of Care (NFLOC) is used, and in order to be designated with requiring this level of care, care must be medically necessary as determined by a physician. Further complicating matters is that there are two levels of care within Florida’s nursing homes, which is intermediate care services and skilled services. Even within the intermediate care level, there is an intermediate level I, as well as an intermediate level II. However, to simplify matters, in order to be determined to need intermediate care, an elderly individual must need 24-hour supervision and also require that medical care be available. For intermediate level I, the applicant’s care needs must be due to a physical or mental impairment. However, skilled nursing services cannot be needed. For instance, the following tasks are considered at this level of care: Medication management, assistance with activities of daily living, such as bathing, eating, dressing, and toiletry, and insulin injections. For intermediate level II, the senior must need limited assistance with health care needs. Said another way, the level of care needed is less than an individual who requires intermediate level I care. For example, individuals must be able to complete daily living activities with minimal assistance. Having said that, assistance with cutting up food, nail clipping, and putting together bathing supplies are examples of assistance provided in intermediate level II care. For skilled services, an individual must require 24-hour care with the availability of professional nursing services. For this level of care, the following type of services may be provided: Intravenous medications, insertion of catheters, and colostomy care.

North Carolina


In North Carolina, a physician must determine that an elderly individual require a Nursing Facility Level of Care. In making this determination, one must have a medical condition that results in the need for care. However, it appears that North Carolina’s requirements for a nursing home level of care might be a bit more lenient than other states. For instance, a senior might get a determination of NFLOC if they need at least 8 hours of care by a registered nurse on a day-to-day basis or if they are on medications and need them to be administered.

Texas

As with all of the states mentioned, in Texas, one must also have a medical need in order to be determined to need a level of care consistent to that provided in a nursing home. The Texas Medicaid & Health Partnership (TMHP), which is the Medicaid claims administrator for Texas, is the one who makes this determination. A registered nurse completes an assessment, known as a Minimum Data Set (MDS), and once this is completed, TMHP conducts a review to determine if care is medically necessary. In order to meet this designation, a Medicaid applicant must have a medical issue that is severe enough that the needs are greater than can be handled by an individual who is untrained to provide care and the applicant must need care provided by a licensed nurse. To satisfy the criteria that care is medically, a physician must deem the care necessary and care must be needed on a consistent basis.