"Nursing Home Level of Care" - What Is It?
Nursing Home Level of Care (NFLOC) – Quick Facts
A state-defined measure of medical, functional, and sometimes behavioral needs required to qualify for Medicaid-funded nursing home care.
Through a state-specific functional assessment that reviews ADLs, health needs, cognitive status, and behaviors.
Yes—there’s no federal definition, and standards, tools, and scoring methods differ across states.
At least once every 12 months to ensure the individual still meets the care level criteria.
What is “Nursing Home Level of Care” (NFLOC)?
A Nursing Home Level of Care (NHLOC), also called Nursing Facility Level of Care (NFLOC), is a set of care criteria a person must meet to be eligible for Medicaid-funded nursing home services. This level is also often used to determine eligibility for long-term care through a Home and Community Based Services (HCBS) Medicaid Waiver. While similar criteria may exist for personal care assistance under a state’s Regular Medicaid program (Aged, Blind, and Disabled Medicaid), the requirements are typically less strict than those for NFLOC.
There is no single federal definition of NFLOC—each state creates its own standards. Most states consider a mix of the following four areas when making this determination:
1) Physical Functional Ability
Evaluates the ability to perform Activities of Daily Living (ADLs)—such as bathing, dressing, toileting, mobility, and eating. States may also look at Instrumental Activities of Daily Living (IADLs) like grocery shopping, meal prep, housekeeping, laundry, medication management, and bill paying.
2) Health Issues / Medical Needs
Includes the need for services such as injections, catheter care, or IV medications that require skilled nursing intervention.
3) Cognitive Impairment
Assesses judgment, memory, and decision-making—particularly relevant for Alzheimer’s disease, Parkinson’s dementia, or Lewy body dementia. Unsafe decision-making may indicate a need for supervised care.
4) Behavioral Problems
Behavioral challenges—such as wandering, aggression, or impulsivity—are often considered, especially in mid-to-late stage dementia.
How do states determine NFLOC?
States use functional assessment tools—paper or digital questionnaires—covering ADLs, medical needs, cognitive function, behavior, and available family support. Many states assign points for different needs; meeting or exceeding a minimum score can qualify a person for NFLOC. Others require a set number of ADL deficits or specific medical conditions confirmed by a physician.
Because assessment methods differ widely—over 120 tools exist nationwide—a person qualifying in one state may not qualify in another.
Why is NFLOC important for Medicaid eligibility?
Without meeting the NFLOC requirement, Medicaid will not cover nursing home care. Some Medicaid Waivers also require NFLOC for in-home services like personal care, adult day care, or adult foster care.
What is the functional assessment process?
The process varies by state and program, but typically includes:
- Initial screening forms covering living situation, ADLs, behavioral or cognitive issues, and health concerns.
- Applicant consent and possibly a release form to gather medical records.
- A face-to-face evaluation—often at home—to observe abilities, ask questions, and gather input from family or care providers.
- Scoring the assessment to determine eligibility and possibly create a care plan.
When is the functional assessment done?
The assessment occurs early in the Medicaid application process and is as important as financial eligibility review. Federal law requires decisions within 45 days (90 days for disability cases), so the assessment is completed before that deadline.
Who pays for the NFLOC determination?
Since it’s part of the Medicaid application process, Medicaid covers the cost.
Is NFLOC reviewed regularly?
Yes—states require a redetermination at least annually to confirm the applicant still meets the care need standard.
