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Glossary

Nursing facility level of care

The eligibility threshold for Medicaid home and community-based waivers and for PACE: the person's needs would qualify them for care in a nursing facility, and they are served at home instead. Each state defines the criteria and determines it on a physician-signed instrument supported by clinical documentation.

Also NFLOC, NF LOC, nursing home level of care, institutional level of care

A home and community-based services waiver exists because the person could be in an institution. Section 1915(c) lets a state pay for care at home only for people who meet the level of care the waiver is tied to, and for most waivers serving older adults and adults with disabilities that is the nursing facility level. 42 CFR 441.302(c) requires the state to evaluate the need for that level of care before services start and to reevaluate it at least annually. PACE uses the same threshold, determined by the state administering agency under 42 CFR 460.150.

What “nursing facility level of care” means is the state’s to define, and the definitions differ in the details and agree in the shape: a need for assistance with a stated number of activities of daily living, or a medical condition requiring skilled oversight, or a cognitive impairment that makes the person unsafe without supervision, established by a professional assessment and supported by a physician.

Three things follow for an agency handling the application:

  • The determination is a document. Every state runs it on a level-of-care form, physician-signed, and a functional assessment by the state’s assessor or the agency’s own nurse.
  • The form needs records behind it. The physician attests to diagnoses, hospitalizations, medications and function. Those sit in the hospital’s, the specialists’ and the primary care practice’s records, and the physician will not sign what the records do not show.
  • The clock is the state’s. The determination runs on a deadline, and a request for information from the reviewer runs on a shorter one. The agency that holds the records on day one is the one whose applications do not stall on the physician’s desk.

NFLOC is an acronym the states use and search engines do not know; New Mexico, Louisiana and Indiana write it on their forms. Records for the Medicaid waiver case management agency is the page about having the documentation in hand before the form goes to the doctor.

Where it is defined

Vivlio for case managementThe physician's documentation behind the level-of-care form, retrieved before the state's clock runs out.

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