What is Nursing Facility Level of Care?

Level of care is the minimum needs an individual must have to be considered eligible for HCBS waiver services. A nursing facility level of care is required for a person to be admitted into a nursing facility. Level of care is evaluated when a person applies for Medicaid and then at least once a year after that. The initial level of care determination is made by the Area Agency on Aging (AAA). The waiver case manager will complete an annual level of care evaluation for waiver services.

For the purposes of nursing facility level of care, a person must have one of the following:

• An unstable, complex medical condition, which requires direct assistance from others for the following: decubitus ulcers, comatose condition, or management of severe pain
• Need for direct assistance from others for medical equipment, such as a ventilator, suctioning, tube feeding, central intravenous access (I.V.)
• Need for direct assistance for special routines or prescribed treatments from others, such as tracheotomy, acute rehabilitation conditions, administration of continuous oxygen
• Need for medical observation and physician assessment due to a changing, unstable physical condition
• Other substantial medical conditions.

Available Waiver Services

Eligible individuals may receive authorized waiver services in conjunction with Traditional Medicaid. Authorized waiver services may include:

• Adult Day Service
• Adult Family Care
• Assisted Living
• Attendant Care
• Self-Directed Attendant Care
• Case Management
• Community Transition
• Environmental Modifications
• Environmental Modification Assessments
• Health Care Coordination
• Homemaker
• Home Delivered Meals
• Nutritional Supplements
• Personal Emergency Response System
• Pest Control
• Respite
• Specialized Medical Equipment and Supplies
• Structured Family Caregiving
• Transportation
• Vehicle Modifications

The specific services that meet the needs of the individual member are identified by the member’s case manager. These services are submitted by the state agency for approval and are listed on the member’s Plan of Care (POC)/Notice of Action (NOA).

Member Information

• To apply, go to your local Area Agency on Aging (AAA). There are 16 Area Agencies on Aging throughout the State. It is helpful to apply as soon as you identify a need for waiver services.

• You must also apply for Medicaid.  You can learn more about applying for Medicaid by going to the Apply for Coverage webpage. If you have been denied Medicaid eligibility before applying for HCBS services, you can re-apply after visiting an AAA office.

Provider Information

• To become a Medicaid provider under the PathWays for Aging, Health and Wellness, and Traumatic Brain Injury Waivers, a provider must first be certified by the Indiana Family and Social Services Administration, Office of Medicaid Policy and Planning. Waiver providers can be certified to provide multiple waiver services. More information about the certification process can be found here.
• After certification, the provider must enroll as an Indiana Health Coverage Programs (IHCP) provider. Visit the IHCP Become a Provider webpage for more information about that process. Note that some providers also offer nonwaiver services within the IHCP. These providers are issued two unique provider identification numbers for billing purposes - one for waiver billing and one for nonwaiver billing. Providers must submit claims using the provider ID that corresponds to the services entered on the claim. The waiver services that can be provided to an A&D waiver member are limited to those listed on the member’s individualized POC/NOA.
• For more information about providing Health and Wellness, and Traumatic Brain Injury waiver services, see the Division of Disability and Rehabilitative Services Home and Community-Based Services Waivers provider reference module and the Home and Community-Based Services Billing Guidelines provider reference module. Information about providing PathWays for Aging waiver services can be found in the Office of Medicaid Planning and Policy Home and Community-Based Services Indiana PathWays for Aging Waiver provider reference module.