What Is Nursing Facility Level of Care? NFLOC Explained

When a family applies for Medicaid to pay for a nursing home or in-home care, the money rules are only part of the test. The other part is clinical: whether the person needs the level of care a nursing facility provides, and that bar is set in your own state's rules rather than in one federal definition.1

What Is Nursing Facility Level of Care (NFLOC)?

The federal nursing-home statute supplies no eligibility test of its own. What 42 U.S.C. 1396r(e)(5) requires is that each state specify the instrument its nursing facilities use for the comprehensive assessment of a resident's functional capacity, which is a rule about assessing people who already live in a facility rather than a screen an applicant passes.1

Ohio's rule turns on three kinds of need: help with Activities of Daily Living (ADLs) such as bathing, dressing, and mobility; skilled nursing or skilled rehabilitation services; and cognitive impairment serious enough to need twenty-four-hour support to prevent harm. Inside Ohio's rule those needs are alternatives, so an Ohio applicant can meet that part of the test on functional need alone, on a skilled service alone, or on cognitive need alone. Ohio also sets other conditions that must be met alongside it, covered below.1 What another state requires is that state's own rule to set, so read it rather than reading across from Ohio's.

Why Nursing Facility Level of Care Matters

A state's Medicaid plan sets a level of care a person must need for nursing facility coverage, and the community pathways carry the same kind of test.3 Under a 1915(c) waiver, each enrollee must independently be evaluated as needing the institutional level of care the waiver substitutes for, and reevaluated at least annually.2 PACE sets it as one of four basic conditions for enrolling, alongside being 55 or older, living in the PACE organization's service area, and meeting any program-specific conditions in the PACE agreement.3 Meeting the financial rules does not settle it: a waiver or PACE applicant also has to meet the level-of-care test.

For a family, a denied level-of-care finding can close off Medicaid payment through each of those routes: nursing facility coverage under the state plan, a 1915(c) waiver, and PACE.

What the Assessment Measures

These are the three areas Ohio's rule turns on, described in plain terms.1 Your own state's assessment form is where to confirm what it scores and what it takes to pass.

1. Physical function (ADLs). Can the applicant bathe, dress, groom, use the toilet, eat, and get around without help? Ohio counts help with at least two of those ADLs, or with one ADL plus help with medication administration. Tasks such as preparing meals, housekeeping, and handling money, often called Instrumental Activities of Daily Living (IADLs), are not on Ohio's ADL list.1

2. Skilled nursing or skilled rehabilitation. Does the applicant need services that call for a skilled nurse or therapist? In Ohio, needing at least one skilled nursing service or skilled rehabilitation service is one of the four routes.1

3. Cognitive and behavioral impairment. Memory, judgment, safety awareness, and orientation, plus behaviors such as wandering, aggression, or resistance to care. Does the applicant forget medications, leave the stove on, wander from home, or fail to recognize danger? In Ohio a diagnosis alone is not the test: the cognitive route asks whether the person needs twenty-four-hour support to prevent harm due to a cognitive impairment diagnosed by a physician or other licensed health professional.1

Ohio's rule shows how those areas combine, and it is the one this page states. Under Ohio Administrative Code 5160-3-08, effective July 1, 2025, Ohio's intermediate level of care has four conditions, and all of them must be met. The person's long-term care needs must exceed the criteria for Ohio's protective level of care; must fall short of the criteria for its skilled level of care; must not meet the developmental disabilities level of care, unless an Ohio Department of Medicaid-approved assessment finds an immediate need for support or a level II PASRR screening finds a need for nursing facility services; and must include a minimum of one of the following: help with at least two ADLs; help with one ADL plus medication administration; at least one skilled nursing or skilled rehabilitation service; or twenty-four-hour support to prevent harm due to a cognitive impairment. For ADL purposes Ohio counts mobility, bathing, grooming, toileting, dressing, and eating. Those four needs are alternative routes inside Ohio's own rule, not a picture of how the bar moves from state to state.1

How the Assessment Works

Each state runs its own process, so treat the steps below as a general outline and use your state's notices for the specifics:

1. Referral or application. The applicant or family files a Medicaid long-term care application, or a hospital discharge planner makes a referral.
2. Assessment scheduled. The agency or program assigns someone to assess the applicant. In Texas, HHSC uses Form H2060 to document an applicant's needs and functional impairments for state-plan personal assistance services.4
3. The visit. The assessor asks about daily routines, reviews medications, and looks at how the applicant manages at home. Have a family member or caregiver there who can answer questions the applicant cannot.
4. Medical records review. Gather recent doctor notes, hospital discharge summaries, and medication lists. Some programs also want a practitioner's statement: Texas Community Attendant Services requires the need to be documented on Form 3052, the Practitioner's Statement of Medical Need, and a regional nurse must verify the medically related health problem.5
5. Scoring and decision. The applicant is scored against the state's tool and gets a determination. In Texas, the Form H2060 score also sets a weekly service-hour level.4 Ask the agency when to expect a decision.

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. Describe a typical day, not a best day.

Texas: Form H2060

Texas uses Form H2060 (the Needs Assessment Questionnaire and Task/Hour Guide) as the functional assessment for Texas Medicaid state-plan personal assistance services (PAS). HHSC uses it to collect and document what an applicant needs from PAS, to assess functional impairments and the ability to perform ADLs, and to set a score and a weekly service-hour level.4

Texas programs that use Form H2060:4,5

• Primary Home Care (PHC) and Community Attendant Services (CAS). A minimum score of 24 on Form H2060 is required, plus the need for at least six hours of service per week. Someone who needs fewer than six hours a week may still be eligible under listed exceptions, such as needing the service to support a caregiver, receiving VA aid and attendance, or being assessed at high risk of institutionalization without it.
• Family Care. Applicants must score at least 24 on Form H2060 to be eligible.
• STAR+PLUS. H2060 determines whether an applicant meets the eligibility requirement score for state-plan PAS in STAR+PLUS, and it sets weekly PAS hours for both STAR+PLUS and STAR+PLUS HCBS. One exception matters: an impairment score is not required for eligibility for STAR+PLUS HCBS services.

The H2060 scoring tool is public and can be downloaded from the Texas Health and Human Services forms library.

Medical Necessity vs. NFLOC

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

• Medical need: A practitioner's statement about the applicant's medical condition. In Texas Community Attendant Services it is Form 3052, the Practitioner's Statement of Medical Need.5
• NFLOC: A determination that the applicant needs nursing-facility-level care in daily life. Ohio's rule, for one, decides it on ADLs, skilled services, and cognitive need.1

Some programs require both. Texas CAS does: a qualifying Form H2060 score, plus the Form 3052 statement and a regional nurse's verification of a medically related health problem.5 Where a program requires both, having one without the other is not enough. Which determinations a program applies, and the score it sets, vary by state and by program, so read the rules for the specific program you are applying to.

If You Don't Meet NFLOC

Not meeting NFLOC does not rule out every kind of help. Each program below has its own rules, so check them where you live:

• State-plan personal care. In Texas, Community Attendant Services (CAS) has its own functional test (a score of at least 24 on Form H2060) for people eligible for Medicaid in a community setting, and provides non-technical attendant services to people with medical conditions resulting in a functional limitation in performing personal care: up to 50 hours per week, or no more than 42 hours per week for a recipient with priority status.5 How a CAS request enters the system is set by HHSC handbook rule: for a person who does not already receive SSI or SSI-related Medicaid, the intake screener must assign the request for personal attendant services to a caseworker as a CAS application, must not screen the applicant for a specific service, and does not place the person's name on the Family Care interest list. It is the caseworker who determines whether a person is placed on the interest list.5
• Section 1915(i) state plan HCBS. A Medicaid state plan option that lets a state cover home and community-based services through a state plan amendment approved by CMS rather than through a federal waiver. Only a minority of states operate one, and the roster changes year to year as states add or end benefits, so check whether yours does.6
• Medicare home health. A separate program with its own test: Medicare covers intermittent skilled care at home for someone who is homebound and under a practitioner's plan of care, from a Medicare-certified agency. It does not cover 24-hour care, or personal care when that is the only care needed.7
• Programs outside Medicaid. Ask your state's aging services agency whether it runs caregiver or in-home support programs, and what they require.

How to Appeal an NFLOC Denial

Federal Medicaid law gives an applicant whose claim for eligibility or covered services is denied the right to a fair hearing before the state agency.8 The process:

1. Read the denial notice carefully. Find the reason it gives and the deadline it sets.
2. File the appeal within the deadline. Federal rules cap a state's window at 90 days from the date the notice is mailed, and a state may set a shorter one, so the deadline on your own notice is the one that counts.9
3. Request a fair hearing. This is a formal hearing before the state agency, where 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. Ask about a new assessment. If the applicant's condition has worsened since the first assessment, or relevant medical records were missing, ask the agency whether a new assessment can be done while the appeal is pending.

If the hearing goes against you, an elder-law attorney or a legal aid office can tell you what further review your state allows.

Common Misconceptions

"A dementia diagnosis means I meet NFLOC." Not by itself. Ohio's cognitive route, for example, asks whether the person needs twenty-four-hour support to prevent harm due to the impairment, not only whether a diagnosis exists.1 How your state weighs dementia is set in its own rule.

"My parent's doctor has to write the NFLOC determination." For PACE, federal rules give the level-of-care determination to the state administering agency, not the doctor.3 A practitioner's statement can still be one input: in Texas CAS, it is Form 3052.5

"If I qualify for Medicaid, I automatically meet NFLOC." No. Qualifying financially is a separate question. Long-term-care Medicaid turns on a level-of-care finding: a 1915(c) waiver enrollee must be evaluated as needing the institutional level of care the waiver substitutes for,2 and PACE requires the state administering agency to determine that the person needs the level of care the state Medicaid plan requires for nursing facility services.3 Being on Medicaid does not by itself mean you meet it.

"The assessment is a medical exam." In the programs on this page it is a needs assessment. Texas's Form H2060, for instance, is a needs questionnaire that documents functional impairments and the ability to perform ADLs.4

Related Terms

• Activities of Daily Living (ADLs): Everyday self-care tasks. Ohio's rule counts mobility, bathing, grooming, toileting, dressing, and eating.1
• Instrumental Activities of Daily Living (IADLs): Meal prep, medication management, housekeeping, and finances: household tasks rather than self-care.
• Medical need statement: A practitioner's statement of the applicant's medical need, such as Texas's Form 3052, which Texas CAS requires alongside its functional assessment.5
• ICF/IID Level of Care: The level of care of an intermediate care facility for individuals with intellectual disabilities, one of the three institutional levels a 1915(c) waiver can substitute for.2
• Form H2060 (Texas): The Needs Assessment Questionnaire and Task/Hour Guide used in Texas for functional scoring.
• Minimum Data Set (MDS): A resident assessment instrument for nursing facilities. Federal law requires each state to specify the instrument its facilities use to assess residents, which is a tool for people already in a facility rather than a screen an applicant passes.1
• HCBS waiver: The Medicaid pathway that delivers home-based care instead of facility care. A 1915(c) waiver reaches only people who, without those services, would require the level of care a hospital, nursing facility, or ICF/IID provides.2
• Managed Care Organization (MCO): A Medicaid health plan. If your state delivers long-term care through one, ask the plan what role it plays in your assessment.

Learn More

Find personalized help understanding senior care benefits at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.