A nursing home level of care refers to the level of care designation used to determine if an individual is eligible to receive Medicaid funding for nursing home care. A nursing home level of care is also used to determine if an individual is eligible for long-term home care funded by Medicaid.

Unfortunately, the definition of nursing home level of care varies from state to state, with no state having the same regulations and the descriptions tend to be rather confusing.  So, here is a simple, general description to help you determine whether your loved one qualifies.

Simple, General Description

If the individual is not able to take care of themselves for an extended period of time and if being without assistance would put them in danger, then they probably meet the requirement to receive Medicaid, based on the nursing home level of care.  Most states require that the person is not able to take care of them self in more than one area.  Here are the four areas of concern:

  • Medical – the individual requires assistance with medical devices such as catheters or ventilators.
  • Cognitive – the individual suffers from memory issues due to Alzheimer’s or other forms of dementia.
  • Behavioral – the individual is not able to control either their actions or their moods.
  • Functional – the individual is not able to handle the daily activities of life such as dressing themselves or eating.

First Step When Looking to Apply for Medicaid

Your first step should be to contact your state Medicaid office.  The state probably has a list of doctors, therapists, and administrators that they will want to use throughout the process.  From there you can start the process.

Nursing Facility Services

Nursing homes certified by Medicaid typically offer the following services:

  • Skilled nursing and other medical care or related services
  • Rehabilitation required following an injury, disability, or other illness
  • Long-term care, which provides care and services related to health issues that are not available elsewhere in the community for those that require regular care due to some physical or mental condition.

When/Where Nursing Facility Services are Provided

Only services provided in a nursing home that is licensed and certified by the state as a Medicaid Nursing Facility are eligible for Medicaid coverage.  These Medicaid services are only available when the individual has no other method to pay the fees and he or she is eligible for the Medicaid program.

Services Included in the Medicaid Nursing Facility Benefit

All Medicaid nursing facilities are required to provide any necessary nursing or other health related services as well as specialized rehabilitation services to allow the patients to attain or at least maintain the highest quality of life possible.  This quality of life includes physical, mental, and social well-being.

There is no specific list of required services, but rather the nursing facility must meet the unique needs of each patient that will bring them that highest possible quality of life.  Those services are determined on a person-by-person basis and are included in that person’s plan of care.

Difference between Medicaid and Medicare

Medicaid covers the cost of nursing home care for those individuals who need that level of care and meet the financial eligibility requirements of the program. This is true in all 50 states.  It is important to remember that the level of care requirements as well as the financial eligibility requirements vary across the states.  Financial eligibility is also dependent on the individual’s marital status. Typically, Medicaid pays for the entire cost for nursing home care, which includes all care as well as room and board.  Medicaid covers those costs indefinitely, as long as the individual requires the services. This is where Medicaid and Medicare differ.  Medicare only covers a portion of the nursing home care costs and only to a maximum of 100 days.