Level of Care Required to Be Eligible for Medicaid Long Term Care

Summary
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 differ for each type of Medicaid program and vary from state to state. When it comes to long-term care, most 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 specific 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 modifications for safety and accessibility, like wheelchair ramps.

For most HCBS Waiver programs, applicants are required to need a Nursing Facility Level of Care (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 Medicaid offers many services similar to the HCBS Waivers described above, including help with the Activities of Daily Living, home modifications and medical equipment. A difference between ABD Medicaid and the other types listed here is that ABD Medicaid applicants are not required to need a Nursing Facility Level of Care. The only functional requirement for ABD Medicaid for seniors is being age 65 or older. However, to receive long-term care services and supports through ABD Medicaid, a person has to show a medical need for those long-term care benefits. In those cases, ABD Medicaid beneficiaries are approved for long-term care benefits one at a time and one an as-needed basis. This is different than Nursing Home Medicaid, which provides all long-term care benefits at the same time.

ABD Medicaid can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for financially limited people of all ages.

 Find Medicaid Eligibility Requirements: An easy way for a Medicaid applicant to find the financial eligibility criteria specific to their situation is through our assessment tool. Start here.

 

Understanding Nursing Facility Level of Care

Someone who requires a Nursing Facility Level of Care (NFLOC) needs the kind of full-time care and supervision, both medical and non-medical, that can is normally associated with a nursing home. As mentioned above, this is the medical or functional criteria to receive Nursing Home Medicaid coverage. Requiring an NFLOC is also the medical criteria to receive long-term care through most Home and Community Based Services (HCBS) Waivers, although not all of them. The third type of Medicaid Long Term Care, Aged, Blind, and Disabled (ABD) Medicaid, does not require an NFLOC.

 

How is Nursing Facility Level of Care Determined?

There is not a standard definition of Nursing Facility Level of Care (NFLOC) across the country. Each state is allowed to use it’s own. In general, however, each state will evaluate a Medicaid applicant’s care needs and see if they reach their definition of NFLOC by measuring some combination of the following factors:

  • Applicant’s ability to complete the Activities of Daily Living (detailed below)
  • Applicant’s ability to complete Instrumental Activities of Daily (detailed below)
  • Medical needs (IVs, catheters, etc.)
  • Cognitive impairment (especially relevant for applicants with dementia)
  • Behavioral issues like aggression or impulsiveness

Every state has a method for assessing level of care needs. 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 test in order for someone to qualify for Medicaid Long Term Care. It could be as simple as needing help with a specific number of the Activities of Daily Living, or there may be multiple steps including an actual diagnosis from one’s doctor.

 Caution: The financial criteria and level of need requirements to receive Medicaid Long Term Care differ depending on the state. Just because one qualifies for Nursing Home Medicaid, HCBS Waivers, or ABD Medicaid in one state does not mean they also qualify in a different state.

 

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

The Activities of Daily Living (ADLs) and the Instrumental Activities of Daily Living (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 can be broken down into five categories:

  • Mobility (getting out of bed or a chair, and the ability to move from room to room)
  • Bathing (includes grooming such as brushing teeth and hair, trimming nails, etc.)
  • Dressing
  • Eating
  • Toileting

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. The following are examples of IADLs:

  • Housekeeping
  • Managing medications
  • Managing money
  • Cooking
  • Shopping
  • Driving
  • 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.

 Tools: We can help with the application process for Medicaid Long Term Care. Follow these links for step-by-step guides through the application process: Nursing Home Medicaid; HCBS Medicaid waivers; Aged, Blind and Disabled Medicaid.