What is Nursing Facility Level of Care?

To be eligible for services, an individual must meet the required "nursing facility level of care."  Level of care is the minimum need an individual must have to be considered eligible for HCBS waiver services. Level of care is evaluated both when you apply and then at least once a year after that.  The initial level of care determination is made by the Area Agency on Aging.  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 conditions: decubitus ulcers, comatose condition, or management of severe pain
• Direct assistance from others for medical equipment, such as ventilator, suctioning, tube feeding, central intravenous access
• Direct assistance for special routines or prescribed treatments from others, such as tracheotomy, acute rehabilitation conditions, administration of continuous oxygen
• Medical observation and physician assessment due to a changing, unstable physical condition
• Other substantial medical conditions

Level of care is required in order for the person to be admitted into a nursing facility or initially start waiver services. The waiver case manager will complete an annual level of care evaluation for waiver services.

What is ICF/IID Level of Care?

To be eligible for intellectual disability services, an individual must meet the required ICF/IID level of care. Level of care is the minimum need an individual must have to be considered eligible for HCBS waiver services. Level of care is evaluated when you apply and then at least once a year after that. For the purposes of ICF/IID level of care, a person must have a disability that:

• Results in impairment of functioning similar to that of a person who is intellectually disabled, including autism spectrum disorder, epilepsy, cerebral palsy, or a similar condition (other than mental illness)
• Originates before the person is 22 years of age
• Has continued or is expected to continue indefinitely
• Substantially limits the person's ability to function normally in society in three of the six major life areas: self-care, receptive and expressive language, learning, mobility, self-direction, and capacity for independent living
• Requires access to 24-hour assistance, as needed

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 Service
• Attendant Care
• Behavior Management/ Behavior Program & Counseling
• Care Management
• Community Transition
• Home and Community Assistance
• Home Delivered Meals
• Home Modifications
• Home Modification Assessment
• Integrated Health Care Coordination
• Nutritional Supplements
• Personal Emergency Response System
• Pest Control
• Residential Based Habilitation
• Respite
• Specialized Medical Equipment and Supplies
• Structured Day Program
• Structured Family Caregiving
• Supported Employment
• 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 to 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 TBI waiver, a provider must first be certified by the Indiana Family and Social Services Administration, Office of Medicaid Policy and Planning (FSSA, OMPP). Waiver providers can be certified to provide multiple waiver services. To find out more about the certification process, visit the DA’s Indiana Home and Community Based Services Waiver webpage.

• After certification, the provider must then enroll as an Indiana Health Coverage Programs provider. Visit the Complete an IHCP Provider Enrollment Application page 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 number that corresponds to the services entered on the claim. The waiver services that can be provided to a TBI Waiver member are limited to those listed on the member’s individualized POC/NOA.

• For more information about providing TBI waiver services, see the Office of Medicaid Policy and Planning Home- and Community-Based Services Waiver: Indiana PathWays for Aging and the Home- and Community-Based Services Billing Guidelines provider reference modules.