Level of Care Required to Be Eligible for Medicaid Long Term Care
Summary
The three Medicaid Long Term Care programs relevant to seniors all have medical eligibility requirements in addition to their financial criteria. Applicants must have a functional need for the care they are seeking. The level of care requirements differ depending on the Medicaid program and can also vary from state to state. When it comes to long-term care, most applicants must require a Nursing Facility Level of Care (NFLOC) or at least require assistance with their Activities of Daily Living (ADLs).
Level of Care Requirements for the 3 Types of MLTC
Nursing Home Medicaid: The medical requirement for Nursing Home Medicaid in every state is needing a Nursing Facility Level of Care (NFLOC), which means the kind of 24-hour supervision and care usually associated with a nursing home. However, the exact definition of a NFLOC and how it is measured can vary depending on the state. This is discussed more below.
HCBS Waivers: HCBS Waivers provide long-term care services and supports to eligible applicants who live in their own home, the home of a loved one, an assisted living residence or another location in the community. The medical requirement for most HCBS Waivers is needing a Nursing Facility Level of Care (NFLOC), which means the kind of 24-hour supervision and care usually associated with a nursing home, as mentioned above. There are also a few HCBS Waivers that require applicants only be at risk for needing a NFLOC, a distinction that has to be determined by the state. HCBS Waivers coverage varies depending on the waiver and the state, but it can include benefits like in-home nursing, home modifications for safety and accessibility, durable medical equipment, meal delivery, transportation and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting).
Aged, Blind, and Disabled (ABD) Medicaid: Like HCBS Waivers, ABD Medicaid also covers long-term care services and supports for eligible applicants who live in their own home, the home of a loved one, an assisted living residence or another location in the community. The medical requirement for long-term care benefits via ABD Medicaid is showing a need for those specific benefits. This is a less strict medical requirement than needing a NFLOC, but it also means ABD Medicaid beneficiaries must qualify for their long-term care coverage one benefit at a time. This is different than Nursing Home Medicaid, which provides all long-term care benefits at the same time. The only functional requirements to receive basic healthcare coverage – physician’s visits, prescription medication, emergency room visits and short-term hospital stays – through ABD Medicaid are being aged (65 or over), blind, or disabled.
ABD Medicaid can sometimes be referred to as state Medicaid or regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for financially limited people of all ages.
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 is normally associated with a nursing home. As mentioned above, this is the medical or functional criteria to qualify for Nursing Home Medicaid coverage and most Home and Community Based Services (HCBS) Waivers, although not all of them.
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.
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.