Level of Care Required to Be Eligible for Medicaid Long Term Care
In addition to financial eligibility criteria, all 3 types of Medicaid Long Term Care programs also have a care requirement. Applicants must have a functional need for the care they are seeking. The level of care requirements differs for each type of Medicaid program and varies from state to state. Most often applicants must require a Nursing Facility Level of Care (NFLOC) or require assistance with their Activities of Daily Living (ADLs).
Level of Care Requirements for the 3 Types of MLTC
Nursing Home Medicaid: In order for Medicaid to cover the costs of room and board, medical care, and personal services in a nursing home, one must demonstrate the need for full-time nursing care, also known as a Nursing Facility Level of Care (NFLOC). This means they would not be safe and healthy without residing in a nursing home. The actual functional needs vary depending on the state in which one is applying for Medicaid.
HCBS Waivers: HCBS waivers are meant to keep someone who would otherwise be a candidate to live in a nursing home in their own home or assisted living community instead. Waivers pay for help with activities of daily living (ADLs, listed and described further down in this article), as well as medical equipment and home upgrades like wheelchair ramps.
For one to receive an HCBS waiver in most states, one must demonstrate that they require an NFLOC, meaning that without the services provided at home or in their living community, the recipient would need to move into a nursing home. However, some waivers may have additional care requirements. For example, some waivers may be designed only for persons with Alzheimer’s or other dementias.
Aged, Blind and Disabled Medicaid: ABD or regular Medicaid offers many services similar to the waivers described above, including help with activities of daily living, home upgrades and medical equipment. A difference between ABD Medicaid and the other types listed here is that an NFLOC is not necessarily required. In other words, the level of care needs is lower for ABD Medicaid than for nursing home benefits or waivers; a recipient can be somewhat independent, requiring less help with activities of daily living.
ABD Medicaid also differs from Nursing Home Medicaid in that beneficiaries must be approved for each benefit individually like traditional health insurance as opposed to Nursing Home Medicaid that approves beneficiaries for the suite of services provided in a nursing home.
Understanding Nursing Facility Level of Care (NFLOC)
Nursing Facility Level of Care is the level of health and/or personal needs required to receive Nursing Home Medicaid. Another type of Medicaid Long Term Care, Home and Community Based Services (HCBS) waivers, often requires a NFLOC, though it depends on where one lives—not every state has an NFLOC requirement to receive Medicaid waivers.
The third type of Medicaid Long Term Care—Aged, Blind and Disabled (ABD) Medicaid, also called Regular Medicaid—usually does not require such a high level of need.
How is it Determined?
There is not a standard, formal definition of NFLOC. It’s up to each state to define exactly what makes someone qualified for Nursing Home Medicaid, Medicaid waivers, and ABD Medicaid.
Generally, a Medicaid applicant’s care needs are assessed to see if they reach the NFLOC threshold by measuring some combination of the following factors:
– Activities of Daily Living (ADL) ability
– Instrumental Activities of Daily Living (IADL) ability
– Medical needs (IVs, catheters, etc.)
– Cognitive impairment (meaning thinking ability, especially for applicants with dementia)
– Behavioral issues like aggression or impulsiveness
Every state has a way of making a needs assessment. Usually, a professional with the local Medicaid office will visit the applicant’s home to ask questions and make observations. A written form is often used to measure in objective-as-possible terms the amount of care someone needs. (See Functional Assessment Tools below.)
Often, there is a score that must be reached on an assessment tool in order for someone to qualify for Medicaid Long Term Care. It could be as simple as needing help with a specific number of ADLs, or there may be multiple steps including an actual diagnosis from one’s doctor.
Cost of Being Assessed
An applicant for Medicaid Long Term Care benefits does not need to pay to be assessed for level-of-care needs. As the assessment is part of the process of approving an application, one can expect to receive an assessment within 90 days of applying, and Medicaid pays for a professional to visit and evaluate care needs.
Understanding Activities of Daily Living & Instrumental Activities of Daily Living
ADLs and IADLs are the normal tasks we do that become difficult, or even impossible, for people who have lost functional abilities due to old age or chronic illness like Parkinson’s or Alzheimer’s disease.
The ability to perform ADLs and IADLs can be easily determined, which makes them an important factor in being assessed when one applies to receive Nursing Home Medicaid, HCBS Waivers, or ABD Medicaid. (Assessing ADLs and IADLs is also important for someone moving into assisted living.) Someone who needs Medicaid Long Term Care assistance, in other words, is unable to perform some of these tasks and requires Medicaid benefits.
ADLs are the day-to-day actions someone who lives independently does for health and safety. ADLs include the following:
– Bathing and/or showering
– Brushing teeth
– Grooming (trimming nails, brushing hair, etc.)
– Using the toilet (continence)
– Getting dressed
– Ambulating (the ability to move from room to room)
– Transferring (getting out of bed or a chair)
IADLs are less day-to-day and not as necessary for safety, but are required to live in a community and maintain quality of life. These are IADLs:
– Managing medications
– Managing money
– Communicating via phone or email
Functional Assessment Tools to Measure ADL and IADL Ability
The specific assessment form a state or program uses to decide if an applicant should be approved for Medicaid Long Term Care benefits is also sometimes called the assessment tool.
For example: The Katz Index of Independence in Activities of Daily Living, or Katz ADL assessment, is used in several states and consists of a checklist of ADLs. Basically, the tool asks whether someone can perform these tasks independently or needs help: bathing, dressing, toileting, transferring (the ability to get in and out of bed or a chair), continence and eating.
A common assessment for IADLs is the Lawton-Brody Instrumental Activities of Daily Living scale, which provides a score between 0 and 8 based on one’s ability to do the following: use the telephone, shop, cook, clean the house, do laundry, use transportation, manage medications and manage money.
Other assessment tools include the Klein-Bell Activities of Daily Living Scale (K-B Scale), the Cleveland Scale for Activities of Daily Living (CSADL) and the Bristol Scale (BADLS). Any of these may be used to determine a Medicaid applicant’s level of independence, and what their functional and/or medical needs are.