Nursing facility (NF) level of care (LOC) is one of two eligibility components (the other is financial eligibility) for Medicaid reimbursement of NF services, as well as home and community based services (HCBS) offered as an alternative to people who would otherwise qualify to receive NF care.
Each State sets its own NF LOC criteria. Approval by the Centers for Medicare and Medicaid Services (CMS) is not required.
Generally, LOC determinations include either an assessment of certain functional needs—the need for assistance with Activities of Daily Living (ADLs); an assessment of certain clinical needs; or both.
Activities of Daily Living (ADLs) consist of self-care tasks that enable a person to live independently in his own home such as:
• Personal hygiene and grooming;
• Dressing and undressing;
• Self feeding;
• Functional transfers (getting into and out of bed or wheelchair, getting onto or off toilet, etc.);
• Bowel and bladder management; and
• Ambulation (walking without use of an assistive device (walker, cane, or crutches) or using a
LOC determinations may also include consideration of other factors which, while not ADLs per se, nonetheless impact a person’s ability to live safely and independently in the community, such as:
• Cognitive status;
• Behavior; or
• The ability to self-administer medications.
And finally, LOC determinations may take into consideration the applicant’s medical or clinical needs such as:
• The need for skilled nursing or rehabilitative care.
The ADL and clinical needs assessed for NF LOC vary by state.
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