Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Level of Care Criteria

12/01/2003

To receive Medicaid coverage of nursing home care, individuals must have functional limitations that match at least one of the following levels:

  1. Dependent in mobility, eating, toileting, and cognition.
  2. Dependent in mobility, eating, and cognition.
  3. Dependent in mobility, or cognition, or eating.
  4. Dependent in toileting.
  5. Needs substantial assistance with mobility, and assistance with toileting and eating.
  6. Needs substantial assistance with mobility and assistance with eating.
  7. Needs substantial assistance with mobility and assistance with toileting.
  8. Needs minimal assistance with mobility, and assistance with eating and toileting.
  9. Needs assistance with eating and toileting.
  10. Needs substantial assistance with mobility.
  11. Needs minimal assistance with mobility and assistance with toileting.
  12. Needs minimal assistance with mobility and assistance with eating.
  13. Needs assistance with toileting.
  14. Needs assistance with eating.
  15. Needs minimal assistance with mobility.
  16. Dependent in bathing or dressing.
  17. Needs assistance in bathing or dressing.6

Services to about 3,600 people in levels 14 to 17 were eliminated in budget reductions in early 2003, and were not restored. Oregon's 2003-2005 budget continues long term care services for people in levels 1 through 11. Subject to federal approval, the budget also restores funding for services to people in levels 12 and 13--about 1,200 clients who need help in such areas as mobility and eating.


6. A computerized scoring system weights and adds multiple measures of physical and mental functioning to determine if the criteria are met. The scoring system is also used to determine reimbursement levels for services provided through the waiver program.

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