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Level of Care

Page posted: 10/01/03

Page reviewed: 5/03/11

Page updated: 5/03/11

Legal Authority

42 C.F.R. 440.10 (Hospital LOC), 42 C.F.R. 440.150 (ICF/DD LOC), 42 C.F.R. 441.301 (LOC requirements for Waivers), Sec. 1919 of the Social Security Act (Nursing facility LOC)

Definition

Level of care: Care and services associated with a particular facility type.

Purpose

Level of care is an eligibility requirement for all disability waivers. LOC identifies the type of waiver and services available to eligible persons. Counties and tribes make a LOC determination for all people seeking a Medicaid waiver.

Find links to the assessment and eligibility forms on each of the applicable disability waiver pages.

ICF/DD LOC

ICF/DD level of care is required for the Developmental Disabilities (DD) Waiver. To meet the requirements for ICF/DD level of care, a person must meet all of the following:

  • • Be in need of continuous active treatment
  • • Have a diagnosis of developmental disability or a related condition
  • • Require a 24-hour plan of care
  • • Require aggressive and consistent training due to an inability to apply skills learned in one environment to a new environment
  • Case Manager’s Guide to Determining ICF/DD Level of Care for ICF/DD and DD Waiver Services DHS-4147A (PDF)

    Nursing Facility LOC

    Nursing facility level of care is required for the:

    A person must demonstrate the need for assistance because of one or more of the following:

  • • Cognitive or behavioral condition
  • • Existence of complicating conditions
  • • Frailty or vulnerability
  • • Functional limitation
  • • Need for complex care management
  • • Need for restorative and rehabilitative or other special treatment
  • • Unstable health
  • To be eligible for the Brain Injury - NF Waiver, the person must require the level of care and types of specialized service available in certain nursing facilities that support persons with brain injury who have significant cognitive and significant behavioral needs.

    Nursing Facility Level of Care Brochure DHS-3361 (PDF)

    Hospital LOC

    Hospital level of care is required for the Community Alternative Care Waiver. A person must meet the four following requirements:

    1. Need professional nursing assessments and intervention multiple times during a 24-hour period to maintain and prevent deterioration of health status.
    2. Have both predictable health needs and the potential for status changes that could lead to rapid deterioration or life-threatening episodes due to the person’s health condition.
    3. Require a 24-hour plan of care, including a back-up plan, to reasonably assure health and safety in the community.
    4. Require frequent or continuous care in a hospital without the provision of CAC waiver services.

    Neurobehavioral Hospital LOC

    Neurobehavioral hospital level of care is required for the Brain Injury Neurobehavioral Waiver. A person must meet the nursing facility level of care and all of the following:

    1. Require specialized brain injury services and/or supports that exceed services available through the TBI-NF Waiver.
    2. Require a level of care and behavioral support provided in a neurobehavioral hospital to support persons with significant cognitive and severe behavioral needs. A person does not have to be a resident of a neurobehavioral hospital to require this level of care.
    3. Require a 24-hour plan of care that includes a formal behavioral support plan and emergency back-up plan to reasonably assure health and safety in the community.
    4. Require availability of intensive behavioral intervention.

    Additional Resources

    Required waiver forms for home and community-based disability waivers

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