What Is Nursing Facility Level of Care (NFLOC)?

By Brevy Care Team · Last verified April 16, 2026

Nursing Facility Level of Care (NFLOC) is a clinical determination that a person needs the kind of 24-hour care and supervision typically provided in a nursing home. Meeting NFLOC is what opens the door to Medicaid long-term care programs: nursing-facility Medicaid, most Home and Community-Based Services (HCBS) waivers that substitute for nursing home care, PACE, and, in some states, home-delivered personal care services.

There is no single federal NFLOC definition. Section 1919 of the Social Security Act tells states to set their own criteria, and each state Medicaid agency publishes its own assessment tool, scoring rubric, and threshold. The result: meeting NFLOC in Texas is not the same as meeting it in California or Florida.

Across states, the assessment looks at four categories: physical function (Activities of Daily Living), medical or skilled-nursing needs, cognitive impairment, and behavioral issues. Some states grant NFLOC if the applicant needs help with as few as 2 ADLs; others require 3 or 4 ADLs plus a qualifying medical or cognitive finding.

Why It Matters

NFLOC is the single clinical test that decides whether Medicaid will pay for long-term care at all. Financial eligibility gets an applicant through the door; NFLOC decides whether the care gets paid for.

For families, a denied NFLOC can mean the difference between $0 and $8,000+ per month in nursing home bills. For people trying to stay at home, it's often the gateway to 30+ hours a week of paid attendant care, home modifications, respite, and case management that regular Medicaid doesn't cover.

The Four Assessment Categories

Most state NFLOC assessments score the applicant in four areas:

1. Physical function (ADLs). Can the applicant independently bathe, dress, toilet, transfer from bed to chair, eat, and walk around their home? Needing help with these is the most common path to meeting NFLOC. Many states also score Instrumental ADLs (IADLs), such as managing medication, preparing meals, housekeeping, and handling finances, but IADLs alone rarely meet the threshold.

2. Medical or skilled-nursing needs. Does the applicant require services that only a licensed nurse can safely provide: injections, wound care, tube feeding, catheter or ostomy care, respiratory treatments, complex medication management? Daily skilled-nursing needs often meet NFLOC on their own.

3. Cognitive impairment. Memory, judgment, safety awareness, and orientation. Does the applicant forget to take medications, leave the stove on, wander from home, or fail to recognize danger? A dementia diagnosis alone does not automatically meet NFLOC in most states — the assessor is looking for functional impact, not just a label.

4. Behavioral needs. Wandering, aggression, impulse control issues, resistance to care. These are often tied to dementia or traumatic brain injury and can meet NFLOC when they require constant supervision.

An applicant rarely scores high in only one area. A typical qualifying profile: needs help with 3 or more ADLs, has moderate cognitive impairment, and takes multiple medications requiring supervision.

How the Assessment Works

The process is broadly similar across states:

  1. Referral or application. The applicant or family files a Medicaid long-term care application, or is referred by a hospital discharge planner.
  2. Assessment scheduled. A state-contracted registered nurse, MCO nurse case manager, or social worker is assigned to visit. Most states require a face-to-face assessment in the applicant's home, hospital room, or facility.
  3. The visit. The assessor spends roughly 60 to 120 minutes with the applicant and, ideally, a family member or caregiver who can answer questions the applicant can't. The assessor observes the applicant moving, asks about daily routines, reviews medications, and looks at the home environment.
  4. Medical records review. The assessor reviews the applicant's recent doctor notes, hospital discharge summaries, and medication lists. In some states, a physician's signature on a "plan of care" form is required.
  5. Scoring and decision. The assessor scores the applicant against the state's published tool and delivers a yes/no NFLOC determination, usually within 30 days. Some states tie the score to an authorized weekly service-hour level.

Be honest during the assessment. Families sometimes coach the applicant to appear more independent than they are. This backfires: a "good day" that shows well can result in a denial or reduced hours. The assessment is a typical-day snapshot, not a best-day performance.

Texas: Form H2060

Texas uses Form H2060 (the "Needs Assessment Questionnaire and Task/Hour Guide") as the primary functional assessment for most Medicaid long-term care programs. A state or MCO case worker completes the form in a home visit, scores the applicant across ADLs and IADLs, and converts the result into a total score and a recommended weekly service-hour level.

Texas programs that use Form H2060:

  • Community Attendant Services (CAS), Primary Home Care (PHC), Family Care. Minimum functional score of 24 required, plus the need for at least 6 hours of service per week.
  • STAR+PLUS HCBS waiver. H2060 is combined with medical-necessity criteria to confirm full NFLOC.
  • HCS, CLASS, TxHmL (I/DD waivers). H2060 is used with additional ICF/IID level-of-care screens.
  • Nursing-facility Medicaid. H2060 plus the federally required Minimum Data Set (MDS) assessment the facility completes.

The H2060 scoring tool is public. A copy can be downloaded from the HHSC forms library.

Medical Necessity vs. NFLOC

These two terms get confused often, but they are not the same thing:

  • Medical necessity (MN). A physician's attestation that the applicant has a medical condition that could require care at a nursing-facility level. It's a diagnostic determination.
  • NFLOC. A functional assessment score showing the applicant actually needs nursing-facility-level help with daily life. It's an activity-based determination.

In Texas and most states, nursing-facility Medicaid requires both: a physician-signed MN form and a qualifying NFLOC score from H2060 or an equivalent. Having one without the other results in a denial.

Applying for Medicaid long-term care and worried about the NFLOC assessment? Chat with Brevy and we'll walk you through what to expect and how to prepare.

If You Don't Meet NFLOC

Not qualifying for NFLOC isn't the end of the road. In most states, several options exist at lower levels of care:

  • State-plan personal care. In Texas, Community Attendant Services (CAS) uses a lower score threshold (24 on Form H2060, versus the higher scores needed for waivers), covers up to 50 hours per week of non-medical personal care, and has no waitlist.
  • 1915(i) state plan HCBS (available in about 20 states). Allows states to cover HCBS services without requiring the full institutional level of care.
  • Community First Choice (CFC, 1915(k)) provides attendant and habilitation services at a level of care broadly similar to NFLOC but available without a waiver waitlist in states that participate.
  • Medicare home health. Short-term, skilled care only, but can bridge a gap after a hospital discharge while an NFLOC application is pending.
  • Paid family leave / state caregiver programs. Some states have non-Medicaid programs that pay family caregivers regardless of NFLOC.

How to Appeal an NFLOC Denial

NFLOC denials are appealable in every state. The process:

  1. Read the denial notice carefully. It must state the reason for denial and cite the specific criteria not met.
  2. File the appeal within the deadline. Most states require 30 to 90 days. The notice will state the specific deadline.
  3. Request a Fair Hearing. This is a formal administrative hearing, typically held by phone or video, in front of a hearing officer. The applicant or their representative presents evidence.
  4. Supplement the record. Before the hearing, gather additional medical records, letters from treating physicians, home-health-agency notes, and a written statement from family about day-to-day needs.
  5. Request a re-assessment. In many states, if the applicant's condition has worsened since the first assessment or if relevant medical records were missing, a second assessment can be requested without waiting for the hearing.

If the Fair Hearing is denied, most states allow a further appeal to state court. An elder-law attorney can help with both steps and sometimes takes these cases on contingency.

Common Misconceptions

"A dementia diagnosis means I meet NFLOC." Not by itself. The assessor looks at functional and behavioral impact, not just the diagnosis. Someone in early-stage dementia who is still independent for most ADLs usually will not meet NFLOC. A diagnosis combined with wandering, safety concerns, or inability to manage medications often does.

"My parent's doctor has to write the NFLOC determination." The doctor doesn't make the NFLOC call. A state- or MCO-contracted assessor does. The doctor's role is completing the separate medical necessity form, which is one input into the broader determination.

"If I qualify for Medicaid, I automatically meet NFLOC." No. Regular (acute care) Medicaid does not require NFLOC. Long-term care Medicaid (nursing facility, HCBS waiver, PACE) does. You can be on Medicaid but not meet NFLOC.

"The assessment is a medical exam." It's not. No labs, no diagnostic testing. It's a functional interview plus records review. Some states train assessors on common mistakes families make trying to coach the applicant's performance.

  • Activities of Daily Living (ADLs): Bathing, dressing, toileting, transferring, eating, and mobility. The foundation of most NFLOC scoring.
  • Instrumental Activities of Daily Living (IADLs): Meal prep, medication management, housekeeping, finances. Secondary inputs into some state scoring.
  • Medical Necessity (MN): The physician-signed attestation of nursing-home-level medical need. A separate input from NFLOC.
  • ICF/IID Level of Care: The parallel criterion used for waivers serving people with intellectual and developmental disabilities.
  • Form H2060 (Texas): The Needs Assessment Questionnaire and Task/Hour Guide used in Texas for functional scoring.
  • Minimum Data Set (MDS): The federally required nursing-facility resident assessment that reconfirms NFLOC after nursing home admission.
  • HCBS waiver: The Medicaid pathway that requires NFLOC to deliver home-based care instead of facility care.
  • Managed Care Organization (MCO): In most states, the MCO's case manager runs or participates in the NFLOC assessment.

Learn More

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. NFLOC criteria, assessment tools, and appeals processes vary significantly by state. Always verify the current rules with your state Medicaid agency or work with a licensed elder-law attorney in your state. Brevy is not a law firm, financial advisor, or healthcare provider.

BC

Brevy Care Team

Expert eldercare guidance from Brevy's team of healthcare professionals and researchers.