What is ‘Nursing Home Level of Care’ According to Medicaid?

When applying for Medicaid’s long-term care coverage, in addition to the strict income and asset limits, you must demonstrate that you need a level of care typically provided in a nursing home.

Whether you are applying for nursing home coverage or through a Medicaid waiver program for help at home, you must meet the level-of-care requirement set by the state. Each state has its own criteria for determining if you meet the mandated level of care, and the criteria are not always clear.

Steps Taken in a Level of Care Determination

The state looks at an applicant’s functional, medical, and cognitive abilities to determine if care in a nursing home is necessary. In general, you must be unable to care for yourself or pose a danger to yourself without outside help. The following are the factors usually considered when making a level-of-care determination:

• You need help with two or more activities of daily living (such as bathing, dressing, eating, moving, and going to the bathroom).
• You need frequent medical care, such as assistance with medication, injections, IVs, or other medical treatment.
• Your cognitive ability is impaired by Alzheimer’s disease or another form of dementia, you have trouble making decisions on your own, or you are unable to process information.
• You have behavior problems, such as wandering away from home or aggressiveness.

Proving a Diagnosis and Need for Care

When assessing a Medicaid applicant, the state will conduct the evaluation. The state may require a doctor’s diagnosis, but it will also likely require the applicant to answer a series of questions about their ability to perform activities of daily living, then evaluate their mental abilities or behavior problems and their family’s ability to provide support.

Your elder law attorney can help you navigate the complex Medicaid application process.