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 or Indiana PathWays for Aging. Authorized waiver services may include:

• Adult Day Service
• Adult Family Care
• Assisted Living
• Attendant Care
• Care Management
• Caregiving Coaching
• Community Transition
• Home and Community Assistance
• Home Delivered Meals
• Home Modifications
• Home Modification Assessment
• Integrated Health Care Coordination
• Nutritional Supplements
• Participant-Directed Home Care Services
• 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 Indiana PathWays for Aging and Health and Wellness 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 Complete an IHCP Provider Enrollment Application page for more information about that process. For the Indiana PathWays for Aging Waiver, providers will also need to enroll in one or more PathWays MCEs (Anthem, UnitedHealthcare, and Humana). 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 a Health and Wellness and Indiana PathWays for Aging waiver member are limited to those listed on the member’s individualized POC/NOA.
• For more information about providing Health and Wellness 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.