Applying for help
What is a level of care determination, and why does it block so many applications?
A level of care determination is the state's finding that someone needs nursing-home-level care. Medicaid cannot pay for a nursing facility stay without one, which makes it the single most common place a family gets stuck after the paperwork is finished and the money is spent down. The test is about function and medical need, not about income, and a low score sends an application back even when every document is in order.
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What the state is deciding
The federal rule is short. Under 42 CFR 440.40, nursing facility services are covered for people aged 21 and over who need that level of care, as determined by the state. Everything after that word "determined" is left to the state: the tool, the threshold, who runs the assessment and how long the result stands.
Two consequences follow. The definition is not portable, so a person approved in one state and moving to another has to be assessed again. And the finding is not permanent. A short-term rehabilitation stay can qualify while a long-term custodial stay in the same building does not, because the test follows the need rather than the address.
The three screens inside one decision
| Screen | What it looks at | Typical evidence |
|---|---|---|
| Functional | Bathing, dressing, toileting, transferring, eating, continence, mobility | Assessment visit, caregiver description, therapy notes |
| Clinical and cognitive | Diagnoses, medications, wound care, supervision needs, orientation, safety | Physician orders, hospital discharge summary, medication list |
| PASRR | Serious mental illness or intellectual or developmental disability | Screening form, psychiatric or psychological records |
The first two screens decide eligibility. The third, the Preadmission Screening and Resident Review under 42 CFR 483.100 through 483.138, decides what has to be arranged before admission. A PASRR finding of specialized services can hold a bed empty for weeks even though eligibility was never in question.
The datapoint families lose points on
Assessments reward specificity. "She needs help around the house" scores lower than "she cannot get out of a chair without a person holding her arm, and she has fallen twice in the last month". Both may be true; only the second describes a measurable deficit.
The pattern repeats across a file: a diagnosis named without its functional effect, a medication list with no note on who administers it, a memory problem described as "forgetful" instead of a documented episode such as leaving a pot on the stove. The assessor can only score what is written down and observed on the day.
Symptoms, causes, and what to do
| What the family sees | Usual cause | Next step |
|---|---|---|
| "Application received" for months with no decision | Assessment not scheduled, or a document request that never arrived | Ask in writing for the assessment date; keep the confirmation |
| Denied as "not needing skilled care" | Chart describes the diagnosis but not the functional loss | Request the assessment tool and score, then file the hearing request |
| Approved for home care but not the facility | Different thresholds for waiver services and facility care | Ask which criterion failed and whether a reassessment is available |
| Facility has a bed, admission still refused | PASRR review unfinished or specialized services unresolved | Ask the state PASRR contact for the written determination |
| Approved, then told coverage ends | Review found improvement, or a level of care that no longer applies | Read the notice's effective date and appeal before it passes |
Home care uses a different threshold
Waiver services under section 1915(c) of the Social Security Act have their own functional eligibility, set by the state, and many states set it higher than the nursing facility test because the goal is to serve people who would otherwise be institutionalised. A person can be too impaired to stay home safely and still score below the waiver threshold, or the reverse. Our guide to Medicaid waivers for home care covers how those waiting lists work separately from the level of care decision.
What to send back after a denial
- The notice itself. It should name the reason and the appeal deadline. Photograph it on arrival; these letters get misplaced.
- The assessment score. Ask for the completed tool. Without it you are arguing against a number you cannot see.
- A functional narrative. One page, dated, describing what the person cannot do unaided, with specific incidents rather than adjectives.
- Clinical support. Physician letter, therapy notes, hospital discharge summary, and any documentation of falls, wandering or missed medication.
- A written hearing request. The right comes from 42 CFR 431.200 through 431.250, and the deadline runs from the notice date.
If the application has not reached an assessment at all, the useful document is not an appeal but a dated follow-up asking for the scheduled date. A record of two unanswered requests changes how the agency handles the third.
Where this fits in the application
Financial eligibility and level of care are checked separately, and failing one does not excuse the other. The application walkthrough covers the documents and the asset test; this page covers the clinical test that runs alongside it. Both feed the same decision letter, which is why a family can be told "over the asset limit" in one paragraph and "does not meet level of care" in the next.
Costs are a separate question again. The nursing home cost guide shows what a facility charges before Medicaid is involved, and what Medicaid covers once it is. Nothing on this page is legal advice, and state assessment rules change with each legislative session.
Frequently asked questions
What is a level of care determination?
It is the state's formal finding that a person needs the kind of care a nursing facility provides. Federal rules at 42 CFR 440.40 tie Medicaid nursing facility payment to that finding, so the state has to assess the applicant before it can pay. The test is functional and medical, not financial, and a family that has already spent down to the asset limit can still fail it.
Who performs the assessment?
Usually the state Medicaid agency, or a contractor it designates, sometimes in combination with the state health department. In many states the same assessment is used for nursing facility admission and for home and community based waiver services, which is why one low score can affect both paths at once.
What does the assessor actually measure?
Activities of daily living such as bathing, dressing, toileting, transferring and eating; continence; cognition and orientation; behaviour that needs supervision; and the medical and skilled-nursing needs documented by a clinician. Most tools also weigh informal support, because a person with a full-time family caregiver at home may score differently from someone living alone.
What is PASRR and why does it delay admissions?
The Preadmission Screening and Resident Review, required by 42 CFR 483.100 through 483.138, applies to anyone admitted to a Medicaid-certified nursing facility who has a serious mental illness or an intellectual or developmental disability. It is a separate screen from the level of care decision and can be the reason a bed is available while the admission is not.
Can a denial be appealed?
Yes. A Medicaid determination carries a right to a fair hearing under the federal regulations at 42 CFR 431.200 through 431.250, and the notice must state the reason and the deadline. The deadline is short, usually measured in weeks, so the request should go in writing as soon as the notice arrives, whatever the appeal ends up arguing.
Sources for this page: 42 CFR 440.40 for the requirement that states determine nursing facility level of care; 42 CFR 483.100 through 483.138 for the Preadmission Screening and Resident Review; 42 CFR 431.200 through 431.250 for the fair hearing and notice requirements; and section 1915(c) of the Social Security Act for home and community based waiver authority. The assessment instruments and thresholds themselves are set by each state Medicaid agency and are not published as a national standard, so no state-specific score appears here. All citations were checked on the day this page was published.
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