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 +|
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|
“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.