Introduction
To qualify for most Medicaid long-term care programs, applicants must require a Nursing Facility Level of Care (NFLOC), even if they live at home or in an assisted living residence. A NFLOC, in general, is the type of 24/7 care and supervision associated with nursing homes. However, the exact definition of a NFLOC, how it’s assessed and who is assessing it can all vary by state. Seniors and their families need to understand the specific variations in their state, and whether or not they meet them, so they can apply for Medicaid at the right time and avoid all the financial, emotional and healthcare consequences of a denial. Keep reading to learn more about NFLOC and Medicaid’s medical requirements, or schedule a free consultation regarding our Level of Care Assessment Service.

 

Medicaid’s Medical Eligibility Requirements

There are some general guidelines that can help explain Medicaid’s medical eligibility criteria:

• To qualify for Nursing Home Medicaid in every state, applicants need a NFLOC.
• To qualify for most Home and Community Based Services (HCBS) Waivers, applicants need a NFLOC. A few waivers only require to be “at risk” of NFLOC.
• To qualify long-term care benefits via regular or state Medicaid, also known as ABD Medicaid, applicants only need to show a need for that specific benefit, so they qualify one benefit at a time.

Not meeting the functional requirements is one of the primary reasons Medicaid long-term care applications are denied, and it is a significant issue. Denied applicants will need to either appeal their denial, which can take up to three months, or re-apply for Medicaid, which can take up to five months. During that time, they will have to pay for care out-of-pocket, which could quickly deplete their savings.

Without Medicaid, a senior may not be able to afford the care they need, or a facility might not be able to hold their bed. Medicaid denials can also take an emotional toll and create a ripple effect of consequences. Being denied for medical reasons can cause uncertainty for seniors and their families, who might hesitate to seek care, take next steps or plan for their future.

In the vast majority of cases, Medicaid long-term care applicants do need serious care, but they just don’t meet their state’s exact criteria of needing a NFLOC, which we will discuss next.

 

Definition of a Nursing Facility Level of Care

The definition of a Nursing Facility Level of Care (NFLOC) can vary by state and tread into some gray areas. In some states, for example, an applicant might need assistance with two of the Activities of Daily Living (mobility, bathing, dressing/grooming, eating, toileting) to qualify for a NFLOC designation, while other states might require they need assistance with three. To further complicate matters, some states may define mobility and the need for assistance with mobility differently than other states.

States will also take behavioral and cognitive issues into consideration when it comes to defining a NFLOC. How much weight they give these issues, however, depends on the state.

NFLOC for Dementia

A diagnosis of Alzheimer’s disease or another dementia does not guarantee a NFLOC designation in any state. However, if a dementia patient does not meet the NFLOC criteria initially, the progressive nature of the disease almost guarantees they will meet it eventually, and our Level of Care Assessment Service could help them determine when that might be. They could then use that time to organize their finances so they can meet Medicaid’s financial requirements, with the help of a professional, or gather all the documents they need for their Medicaid application.

 

Assessing Medical Need

Each state has their own procedures for assessing the medical need of an applicant and whether or not they need a NFLOC. All states will conduct in-person evaluations, but who is conducting them can vary. It might be a state employee, an independent contractor selected by the state, or a third-party selected by the applicant. Some states put more emphasis on this in-person evaluation than the evaluation of the applicant’s primary care provider, but some states do the opposite.

With that in mind, there are some basic approaches all states use when it comes to assessing medical need: They will conduct in-person evaluations, they will consult with the applicant’s care providers, they will assess the applicant’s ability to complete the Activities of Daily Living (ADLs), they will determine how much help the applicant needs with each ADL, they will assess cognitive function in some manner.

Our Level of Care Assessment will do all the same things so seniors and their families can confidently plan for their future. Each assessment is tailored to match the specific Medicaid criteria and process in the state where the client resides. If our assessment determines the client will meet their medical eligibility criteria, but they are then denied for not meeting it, we will stand by the client through the appeal process. This includes providing additional clarification and documentation to the state as needed.

 

How Medical Eligibility Impacts When to Apply

Understanding medical eligibility will help seniors and their families know when it’s time to apply for Medicaid long-term care. Applying too early – before the senior is medically eligible – will mean wasting time on an application process that can take months to complete. It can also mean wasted money for applicants who are using complex Medicaid Planning strategies to reduce their assets in order to qualify. Applying too late – after the senior is medically eligible – will mean paying out-of-pocket for care that could have been covered by Medicaid.

As mentioned above, seniors who don’t meet medical eligibility criteria but have a progressive condition (like dementia) can start preparing for the application and enrollment process. They can implement Medicaid Planning strategies to reduce their assets or income in order to qualify. They can start gathering all the financial documents needed for a Medicaid application. If they’re applying for a HCBS Waiver and it has a waitlist, they could potentially get on the list before applying in order to reduce their wait in the end.

These planning strategies tend to be complicated, so consulting with professionals is recommended attempting to utilize them on your own.