Disability Rights Ohio - Medicaid: Level of Care

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People who apply for Medicaid waiver programs or institutional care must meet “level of care” criteria to be eligible. A level of care determination is a decision made about an individual’s physical, mental, social, and/or emotional status. In Ohio, there are two primary levels of care: “nursing facility” and “developmental disabilities” levels of care.

Note: meeting level of care criteria does not guarantee approval of an application, as there are other eligibility criteria and sometimes waiting lists for services

1. Developmental Disabilities Level of Care

People who meet the developmental disabilities (“DD”) level of care may be eligible for services in an intermediate care facility for individuals with intellectual disabilities (“ICF”) or for the following waiver programs: the Individual Options (IO), Level One, or Self Empowered Life Funding (SELF) waivers.

DD LEVEL OF CARE CRITERIA
Ages 0-9	Ages 10 +
The person has a substantial developmental delay or specific congenital or acquired condition (other than an impairment caused solely by mental illness), and In the absence of individually planned supports, the person has a high probability of having substantial functional limitations later in life in at least 3 of the following areas of major life activities: self-care, receptive and expressive communication, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency.	The person is diagnosed with a severe, chronic disability caused by mental or physical impairment (not caused solely by mental illness) that manifested before age 22 and will likely continue indefinitely, The condition results in substantial functional limitations in at least 3 of these areas: self-care, receptive and expressive communication, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency, and The condition reflects a need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, and other forms of assistance of lifelong or extended duration that are individually planned and coordinated.

DD LEVEL OF CARE CRITERIA

Ages 0-9

Ages 10 +

The person has a substantial developmental delay or specific congenital or acquired condition (other than an impairment caused solely by mental illness), and
In the absence of individually planned supports, the person has a high probability of having substantial functional limitations later in life in at least 3 of the following areas of major life activities: self-care, receptive and expressive communication, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency.

The person is diagnosed with a severe, chronic disability caused by mental or physical impairment (not caused solely by mental illness) that manifested before age 22 and will likely continue indefinitely,
The condition results in substantial functional limitations in at least 3 of these areas: self-care, receptive and expressive communication, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency, and
The condition reflects a need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, and other forms of assistance of lifelong or extended duration that are individually planned and coordinated.

2. Nursing Facility Level of Care

People who meet the nursing facility (“NF”) level of care may be eligible for services in a nursing facility or for the following waiver programs: Ohio Home Care, MyCare Ohio, Assisted Living, and PASSPORT waivers. Someone can meet the NF level of care by meeting either the “Skilled” level of care or the “Intermediate” level of care.

NF LEVEL OF CARE CRITERIA
Intermediate Level of Care	Skilled Level of Care
The person does not meet DD level of care, and The person needs a minimum of one of the following: assistance with 2 activities of daily living (ADLs), assistance with one ADL and assistance with medication administration, one skilled nursing service or skilled rehabilitation service, or 24-hour support in order to prevent harm due to a cognitive impairment.	The person needs a minimum of one of the following: one skilled nursing service per day, 7 days per week, or one skilled rehabilitation service per day, 5 days per week, and The person has an “unstable medical condition.”
Key Definitions: “Activities of daily living” (ADLs) include bathing, dressing (e.g., putting on/taking off clothes), eating, grooming (e.g., hygiene, hair/nail care), mobility (e.g., locomotion, transfers), and toileting (e.g., using a commode, cleansing, managing an ostomy) “Unstable medical condition” means clinical signs and symptoms are present in an individual and a physician has determined that: The individual’s signs and symptoms are outside of the normal range for that individual; The individual’s signs and symptoms require extensive monitoring and ongoing evaluation of the individual’s status and care and there are supporting diagnostic or ancillary testing reports that justify the need for frequent monitoring or adjustment of the treatment regimen; Changes in the individual’s medical condition are uncontrollable or unpredictable and may require immediate interventions; and A licensed health professional must provide ongoing assessments and evaluations of the individual that will result in adjustments to the treatment regimen as medically necessary. The adjustments to the treatment regimen must happen at least monthly, and the designated licensed health professional must document that the medical interventions are medically necessary.

NF LEVEL OF CARE CRITERIA

Intermediate Level of Care

Skilled Level of Care

The person does not meet DD level of care, and
The person needs a minimum of one of the following:
- assistance with 2 activities of daily living (ADLs),
- assistance with one ADL and assistance with medication administration,
- one skilled nursing service or skilled rehabilitation service, or
- 24-hour support in order to prevent harm due to a cognitive impairment.

The person needs a minimum of one of the following:
- one skilled nursing service per day, 7 days per week, or
- one skilled rehabilitation service per day, 5 days per week, and
The person has an “unstable medical condition.”

Key Definitions:

“Activities of daily living” (ADLs) include bathing, dressing (e.g., putting on/taking off clothes), eating, grooming (e.g., hygiene, hair/nail care), mobility (e.g., locomotion, transfers), and toileting (e.g., using a commode, cleansing, managing an ostomy)

“Unstable medical condition” means clinical signs and symptoms are present in an individual and a physician has determined that:

The individual’s signs and symptoms are outside of the normal range for that individual;
The individual’s signs and symptoms require extensive monitoring and ongoing evaluation of the individual’s status and care and there are supporting diagnostic or ancillary testing reports that justify the need for frequent monitoring or adjustment of the treatment regimen;
Changes in the individual’s medical condition are uncontrollable or unpredictable and may require immediate interventions; and
A licensed health professional must provide ongoing assessments and evaluations of the individual that will result in adjustments to the treatment regimen as medically necessary. The adjustments to the treatment regimen must happen at least monthly, and the designated licensed health professional must document that the medical interventions are medically necessary.

Service Denials Based on Level of Care

If your application for services is denied on the basis that you do not meet level of care criteria, or you are losing services because your level of care has changed, you have the right to appeal the decision. To appeal, you should request a state hearing with the Bureau of State Hearings. More information is available in the FAQ “State Hearings and Administrative Appeals.”

Before the hearing, you should gather evidence from treating physicians and other health care professionals to support your appeal. Consider providing the following:

Testimony at the hearing from doctors, therapists, or other healthcare professionals to explain what your needs are and the type and amount of assistance or services you require.
Letters from your doctors, therapists, or other healthcare professionals or providers that explain what your needs are and the type and amount of assistance or services you require.
Prescriptions from your doctors for services such as skilled nursing or rehabilitative services.
Evaluations, assessments, or records completed by your doctors or other healthcare professionals that show what your needs are and what type and amount of assistance or services you require.
Records from recent hospital visits that relate to the conditions for which you are requesting assistance.
Testimony from parents, other family members and caregivers is another way to show what a person’s needs are.

Please contact Disability Rights Ohio if you have questions. Our phone number is 800-282-9181. Select option 2 for the intake department.

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