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Minnesota Department of Human Services Community-Based Services Manual (CBSM)
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Level of care

Page posted: 10/1/03

Page reviewed: 11/15/17

Page updated: 11/15/17

Legal authority

42 C.F.R. 440.10, 42 C.F.R. 440.150, 42 C.F.R. 441.301; 42 U.S.C. 1396r (also known as §1919 of the Social Security Act); Minn. Stat. §144.0724; Minn. Stat. §256B.434; Minn. Stat. §256B.49

Definition

Level of care (LOC): A particular amount of care and services required to meet a person's needs.

Overview

There are four level of care distinctions:

  • • Intermediate care facility for persons with developmental disabilities (ICF/DD)
  • • Hospital
  • • Nursing facility (NF)
  • • Neurobehavioral hospital (NB).
  • Each level of care distinction has criteria that are associated with the services provided in a particular institution type. Needing a particular level of care is an eligibility requirement for the following:

  • • Alternative Care (AC) program
  • • Home and community-based services (HCBS) waivers
  • • MA-funded services provided in a long-term care facility.
  • Determining level of care

    The lead agency determines level of care during an assessment process for people who request home and community-based services under Medical Assistance (MA).

    The lead agency may need to complete an assessment for a person who has been admitted to a nursing facility and requires a final determination of NF level of care. For more information, see DHS bulletin, #17-25-06, section XII (PDF).

    ICF/DD

    For ICF/DD level of care, the person must meet all of the following criteria:

  • • Be unable to apply skills learned in one environment to another (i.e., cannot generalize skills to "real world" situations)
  • • Have a diagnostic determination of intellectual or developmental disability or a related condition
  • • Require a continuous program of aggressive, systemic instruction and supervision (i.e., active treatment) to participate in life activities
  • • Require a 24-hour plan of care based on need for active treatment to gain and/or maintain the highest level of self-sufficiency and life participation.
  • For more information, see:

    HCBS waiver that requires this level of care

    The Developmental Disabilities (DD) Waiver requires a person to need an ICF/DD level of care.

    Hospital

    For hospital level of care, the person must meet all of the following criteria:

  • • Have both predictable health needs and the potential for status changes that could lead to rapid deterioration or life-threatening episodes because of the person's health condition
  • • Require professional nursing assessments and intervention multiple times during a 24-hour period to maintain and prevent deterioration of health status
  • • Require a 24-hour plan of care, including a back-up plan, to reasonably assure health and safety in the community
  • • Require frequent or continuous care in a hospital without CAC Waiver services.
  • HCBS waiver that requires this level of care

    The Community Alternative Care (CAC) Waiver requires a person to need a hospital level of care.

    Nursing facility

    The nursing facility (NF) level of care criteria differs for people younger than 21 years old and people 21 years or older.

    People under 21 years old

    For NF level of care, a person under 21 years old must have or need 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, rehabilitative or other special treatment
  • • Unstable health.
  • For more information, see Nursing Facility Level of Care (Individuals Under 21 Years Old), DHS-3361 (PDF).

    People 21 years or older

    For NF level of care, a person 21 years or older must meet one of the following five categories of need:

    1. Does or would live alone or be homeless without his/her current housing type and meets one of the following:

  • • Has had a fall resulting in a fracture within the last 12 months
  • • Has a sensory impairment that substantially impacts functional ability and maintenance of a community residence
  • • Is at risk of maltreatment or neglect by another person, or is at risk of self-neglect.
  • 2. Has a dependency in four or more activities of daily living (ADLs)

    3. Has significant difficulty with memory, using information, daily decision-making or behavioral needs that require intervention

    4. Needs the assistance of another person or constant supervision to complete toileting, transferring or positioning, and this assistance cannot be scheduled

    5. Needs formal clinical monitoring at least once a day.

    For more information, see Nursing Facility Level of Care Criteria (Individuals Age 21 and Older), DHS-7028 (PDF).

    HCBS waivers/program that require this level of care

    The following require a person to need an NF level of care:

    Additional level of care criteria for the BI-NF Waiver

    In addition to the NF level of care criteria listed above, the BI-NF Waiver requires a person to need the level of care and types of specialized services available in nursing facilities that support people with brain injuries and significant cognitive/behavioral needs.

    Neurobehavioral hospital

    For neurobehavioral hospital (NB) level of care, the person must meet NF level of care criteria and require all of the following:

  • • 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
  • • Availability of intensive behavioral intervention
  • • Level of care and behavioral support available in a neurobehavioral hospital that supports people with significant cognitive and severe behavioral needs (a person does not have to reside in a neurobehavioral hospital to require this level of care)
  • • Specialized brain injury services and/or supports that exceed services available through the BI-NF Waiver.
  • HCBS waiver that requires this level of care

    The Brain Injury Neurobehavioral (BI-NB) Waiver requires a person to have an NB level of care.

    Additional resources

    CBSM – Assessment and support planning
    CBSM – Waiver programs overview

    CBSM – Required waiver forms for home and community-based disability waivers

    DHS – Modification of NF level of care criteria

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