Nursing Home Level of Care is a term used in the Medicaid context to designate an individual who is eligible to receive Medicaid-funded nursing-home care. In other words, it is often the case that in order to receive Medicaid-funded nursing-home care an individual must show that they require Nursing Home Level of Care, or NHLOC for short. Therefore, if you or a senior loved one are thinking about, or are currently receiving, senior care (whether at home or in a community setting) it is important to know whether you could qualify for NHLOC and therefore might be eligible to have some or all of your or your loved one’s care paid for by your state’s Medicaid agency.  

An important thing to keep in mind is that there is no standardized definition of Nursing Home Level of Care across the country, and rather each state is free to define what it considers to be a Nursing Home Level of Care. In fact, some states don’t even use the term Nursing Home Level of Care and instead use similar terms such as Florida who uses the term Nursing Facility Level of Care to refer to their care-based Medicaid requirement. Therefore, it’s important to consult with a local attorney or elder care specialist to determine whether you or your senior loved one qualify for your state’s definition of Nursing Home Level of Care. That being said, the following primer should give a good guide on what is meant by Nursing Home Level of Care in the Medicaid context.

How to determine Nursing Home Level of Care

As noted, there is no single definition of Nursing Home Level of Care that exists throughout the country. Rather, each state has its own standards and processes for determining whether an individual has impairments that would qualify them for long term or nursing home care. But while each state has its own definition of Nursing Home Level of Care, the question whether an individual requires Nursing Home Level of Care is roughly the same throughout the country, and focuses on whether an individual is able to take care of themself and not cause themself any harm for an extended period of time.

To make this determination, state Medicaid agencies generally look at four main criteria: an applicant’s ongoing medical conditions and treatments; an applicant’s cognitive function including whether they suffer from Alzheimer’s or dementia; an applicant’s behavioral trends including whether they can control their moods and actions; and finally a functional assessment of the applicant’s ability to complete the Activities of Daily Living. In addition, some states may look at additional factors like the ability of a senior’s family to provide in-home care. 

On a practical level, a determination that an applicant requires Nursing Home Level of Care will be made by the state Medicaid agency, and often requires that the applicant be assessed by a member of a pre-selected group of doctors, nurses, therapists, or administrators. To learn more about the assessment process in your state, contact a local elder law or senior care expert or reach out to your local state Medicaid office.

Nursing Home Level of Care around the country

Because Nursing Home Level of Care is different for each state, it’s important to determine whether you or your senior loved one qualify according to your own state’s definition. To give an idea of how the definition for being medically qualified for Medicaid changes around the country, please find some examples from some of the country’s largest states below. 

Florida

Under Florida’s Statewide Medicaid Managed Care Long-Term Care Program (SMMC LTC for short) the term Nursing Facility Level of Care is used instead of Nursing Home Level of Care in order to designate someone who meets the care requirement to be eligible for Medicaid. To determine whether an individual requires Nursing Facility Level of Care, an applicant must undergo an assessment conducted by the Florida Department of Elder Affairs which focuses on the care the applicant requires based on their medical history, as well as functional and behavioral needs. Finally, this care must be deemed medically necessary by a physician or registered nurse.

California

Under California’s Medicaid program, known as Medi-Cal, a determination that an individual requires Nursing Home Level of Care must be made by a doctor who has observed the applicant, assessed their treatment history, and found that there is a need for care in a nursing home. Whether a doctor concludes an applicant requires Nursing Home Level of Care will of course be a determination that is made on an individual level. That being said, some conditions might be particularly likely to qualify. For example, an individual might be deemed to require Nursing Home Level of Care if they require around the clock skilled nursing due to something like a feeding tube or a post-surgical recovery. Along with a distinct medical condition, failure to complete several Activities of Daily Living such as being able to regularly take medicine or successfully bathe and dress might qualify as requiring a Nursing Home Level of Care.

New York

In order to be eligible for nursing home care through Medicaid in New York an applicant must have a medical need for nursing home care as determined by a registered nurse after completing an assessment called a Hospital and Community Patient Review Instrument (or an H/C PRI as it’s often referred to in New York Medicaid documents). The PRI includes an assessment of several general areas, including the applicant’s medical history and whether or not they have a listed medical condition or are receiving a listed medical treatment. The PRI also includes an assessment of the applicant’s ability to complete four general categories of Activities of Daily Living: eating, mobility, transferring between positions like from a chair to a bed, and toileting.

Arizona

In Arizona Medicaid funding for senior care is provided through the Arizona Long-Term Care System (known by its acronym ALTCS). An applicant must undergo a pre-admission screening conducted by the Arizona Health Care Cost Containment System, Arizona’s Medicaid agency, in order to determine whether they meet the medical requirements for eligibility. Like other states, Arizona’s pre-admission screening focuses on a mix of the applicant’s medical history as well as their ability to complete all the Activities of Daily Living. While every applicant is different, the pre-admission screening is generally focused on the applicant’s ability to perform their ADL’s including bathing and grooming, food preparation, and toileting and dressing.

To learn more about how Sunbound can help make paying for senior living and senior care more affordable for you or your loved one, send us an email at info@sunboundhomes.com or request more information on Sunbound. Sunbound is the best way to pay for senior living and senior care and is on a mission to make senior living and senior care more affordable for everyone.