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


Applicants for Medicaid coverage of nursing home care must meet one of the following criteria:

  1. Must require licensed nursing care (RN or LVN);

  2. Must meet two or more of the criteria for nursing home risk, as specified in the Resident Assessment Instrument-Home Care Assessment for Nursing Home Risk as revised in April 1996 and summarized as follows:

    • needs assistance with one or more of the activities of dressing, personal hygiene, eating, toilet use, or bathing;
    • has had a functional decline in the past 90 days;
    • has a history of a fall two or more times in past 180 days;
    • has a neurological diagnosis of Alzheimer's, Head Trauma, Multiple Sclerosis, Parkinson's, or Dementia;
    • has a history of nursing facility placement within the last five years;
    • has multiple episodes of urine incontinence daily; and
    • goes out of one's residence one or fewer days a week.
  3. Must have been living for 30 consecutive days in a medical facility that has a contract to accept Medicaid patients. Persons in this category must still be screened for medical necessity.

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