What Is a Nursing Home Level of Care (NHLOC)?

Before a beneficiary can receive certain long-term services and support through Medicaid, they may be required to demonstrate the need for a nursing home level of care. But, what is a nursing home level of care (NHLOC), and how does it affect your Medicaid coverage? Let’s take a closer look at how this often-confusing designation is applied throughout the country.

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What Is a Nursing Home Level of Care (NHLOC)?

A nursing home level of care, abbreviated NHLOC, is a measure of a beneficiary’s care requirements that may be used to determine if a service is reimbursable under Medicaid. It’s typically used in relation to Medicaid’s Home & Community-Based Services (HCBS)  waiver when determining eligibility for nursing home admission or other long-term care and support services.

Depending on your state of residence, a nursing home level of care may also be described using other terms, such as:

• Nursing facility level of care (NFLOC)
• Nursing facility clinically eligible (NFCE)
• Skilled nursing level of care

How Is a Nursing Home Level of Care Determined?

Because the federal government doesn’t universally define the criteria for a nursing home level of care, each state must set its own definition. Specific rules and approved assessment tools vary depending on where you live, and states may use different ranking systems for determining the appropriate level of care for an individual. However, many states consider similar criteria when making a level-of-care determination.

Areas of Consideration

In most states, the level-of-care determination includes a review of four specific areas.

1. Functional Physical Ability

A person’s ability to execute activities of daily living (ADLs) is usually taken into account when determining if they require a nursing home level of care. ADLs are personal care tasks that an individual must be able to complete each day to remain independent. ADLs may include activities such as:

• Eating
• Dressing and undressing
• Walking and stair climbing
• Transferring between a bed and chair
• Personal hygiene tasks such as bathing, grooming and toileting

A second level of activities, known as instrumental activities of daily living (IADLs), may also be taken into account. Although IADLs typically don't need to be done every day, they’re considered essential for independent living. IADLs may include activities such as:

• Laundry
• Housecleaning
• Grocery shopping
• Meal preparation
• Medication management
• Communicating via phone
• Paying bills and other financial management tasks
• Driving a car or accessing public transportation
  
  

2. Medical Needs and Ongoing Health Issues

Most states consider an individual’s ongoing health issues and medical needs when determining whether a Medicaid beneficiary requires a NHLOC designation. Specific needs that may be factored into this determination include:

• Feeding tubes
• Required injections
• Intravenous medications
• Catheter or colostomy care

3. Behavioral Issues

Individuals diagnosed with dementia may exhibit behavioral issues, which are often taken into consideration when assessing level-of-care needs. Behavioral issues may include:

• Impulsiveness
• Physical, verbal and sexual aggression
• Frequent wandering (often leading to becoming lost)

4. Cognitive Impairment

Impaired judgment and other cognitive issues that jeopardize a senior’s safety are often included when assessing level-of-care needs, especially when an individual has been diagnosed with dementia.

The Level-of-Care Determination

Ultimately, the level-of-care determination is based on an assessment of an individual’s ability to live independently. That generally includes a formal diagnosis by a Medicaid-approved physician, and may require additional observation by a trained clinician, such as an RN or a physical, occupational or behavioral therapist. In most states, to be considered eligible for a nursing home level of care, an individual must be unable to care for themselves in two or more ways for an extended period of time, resulting in risks to their health or safety.

Nursing Home Level of Care: How States Differ

The answer to the question “What Is a nursing home level of care (NHLOC)?” changes depending on your state of residence. Here are a few examples, by state, of how the level-of-care status is determined:

California

California’s Medicaid program, Medi-Cal, refers to nursing homes as skilled nursing facilities. In California, reaching a decision that an individual requires a nursing home level of care involves observation, assessment of treatment options and a doctor’s conclusion that nursing home care is needed.

Medical conditions that involve feeding tubes, necessitate professional wound care or require around-the-clock monitoring often lead to a nursing home level-of-care determination. Behavioral issues such as unpredictable moods, depression and anxiety may also indicate the need for skilled nursing facility care in California.

Florida

Florida Medicaid is known as the Statewide Medicaid Managed Care (SMMC) Program. Residents who wish to be considered eligible for a nursing facility level of care (NFLOC) must undergo an interview and assessment, which is conducted by The Department of Elder Affairs using the Comprehensive Assessment and Review for Long-Term Care Services (CARES) screening tool. A NFLOC must be deemed medically necessary by a doctor or RN. Ongoing medical conditions, behavioral factors and functional needs may be considered.

New York

Medicaid beneficiaries in New York must demonstrate a medical need for nursing home care to meet state requirements for this level-of-care designation. A senior’s ability to execute ADLs may also factor into the decision.

The assessment is done using the Hospital and Community Patient Review Instrument (H/C PRI), which is typically administered by an RN. This screening tool looks at an individual’s medical conditions, behaviors, medications and their ability to consistently complete ADLs.

North Carolina

North Carolina seniors may be deemed eligible to receive a nursing home level of care if they have a medical condition that requires medication administration, 24-hour monitoring by a nurse or at least eight hours of care each day. The formal determination must be made by a physician.

Texas

Texas Medicaid also requires seniors to demonstrate a medical need serious enough to require extended professional care before issuing a nursing home level-of-care designation. After an initial assessment by a registered nurse, the Texas Medicaid & Health Partnership (TMHP) completes a review to decide whether a senior requires this level of care.

Regardless of your state of residence, it’s important to remember that rules governing Medicaid may change at any time. Additionally, even statewide rules may be subject to interpretation by local Medicaid administrators.

How Can You Start the Assessment Process?

If you think a loved one is eligible for a nursing home level of care, begin the process by contacting your state’s Medicaid office. Program representatives can provide a list of authorized doctors, therapists or administrators who may perform assessments and make an appropriate determination.