Nursing facility level of care is the clinical finding that controls access to nursing home Medicaid, CCSP, SOURCE, ICWP, and Katie Beckett in Georgia. This guide explains the assessment tools, who runs them, and how families move through the determination.

Nursing facility level of care (NF LOC) is the gatekeeping clinical and functional determination that controls access to nearly every long-term services and supports pathway in Georgia Medicaid. For institutional Medicaid, it decides whether an applicant qualifies for nursing home coverage. For the Community Care Services Program (CCSP) and Service Options Using Resources in a Community Environment (SOURCE), the two service-delivery models inside Georgia's Elderly and Disabled Waiver Program (EDWP), NF LOC is the threshold functional standard. For the Independent Care Waiver Program (ICWP), a hospital or nursing facility level of care is required. For Katie Beckett TEFRA, hospital or nursing facility level of care is the medical criterion that lets Georgia disregard parent income for medically complex children. For Money Follows the Person transitions, NF LOC at the time of institutional residence triggers waiver slot eligibility.

If a hospital social worker has just raised nursing home placement for your parent, the first practical step is to ask which level of care determination applies and who will run it, because that single answer shapes every option that follows. A favorable NF LOC determination opens the door to nursing home Medicaid, CCSP, SOURCE, ICWP, Katie Beckett, or Money Follows the Person, depending on the specific pathway and the other eligibility factors. An unfavorable determination closes that door at the threshold, and the family must look to commercial insurance, Medicare, private pay, or appeal. Misreading the framework leads families to pursue the wrong care setting, miss services their loved one qualifies for, or accept a denial that should have been challenged.

The instruments differ by pathway: the Minimum Data Set 3.0 (MDS) for nursing facility residents, the Preadmission Screening and Resident Review (PASRR) for individuals with serious mental illness or intellectual disability, the Determination of Need-Revised (DON-R) for CCSP and SOURCE applicants, the ICWP functional assessment for physical disability, and the Katie Beckett medical and functional review for children. The underlying logic is consistent: would the person require institutional care if community alternatives were not available? If yes, the person meets the level of care standard and is clinically eligible for the institutional or community-based pathway.

This guide walks through the federal standards at Section 1919 and 42 CFR Part 483, the MDS instrument, the PASRR screening process, Georgia's DON-R tool, the ICWP and Katie Beckett criteria, how level of care interacts with financial eligibility, the Olmstead integration mandate, care planning and reassessment, discharge planning and Money Follows the Person, the difference between Medicare SNF and Medicaid nursing facility coverage, and the appeals framework. Worked examples show how it plays out for real Georgia families, and a phone directory gives you the numbers you need.

Why Georgia nursing facility level of care matters

Level of care is the clinical and functional finding that anchors long-term care eligibility. Georgia runs the determination across several pathways with overlapping but distinct instruments:

  • Institutional nursing facility Medicaid: NF LOC plus financial eligibility under the 300 percent SSI rule, plus spousal impoverishment protection if married
  • CCSP and SOURCE: NF LOC measured by the DON-R plus financial eligibility
  • ICWP: severe physical disability or traumatic brain injury, applying between ages 21 and 64, plus hospital or NF LOC
  • NOW and COMP: developmental disability plus ICF/IID level of care (an analogous determination, not NF LOC)
  • Katie Beckett TEFRA: hospital or NF LOC equivalent medical and functional criteria for the child
  • Money Follows the Person: NF LOC at the time of institutional residence, plus at least 60 consecutive days of institutional residence, a community plan, and a waiver slot

One naming point trips families up constantly. Georgia runs four Section 1915(c) home and community-based waivers: EDWP, ICWP, NOW, and COMP. CCSP and SOURCE are the two service-delivery models inside EDWP, not separate waivers, which is why state paperwork may name EDWP where a family expected to see "the CCSP waiver." SOURCE adds enhanced case management coordinated through a primary care physician.

Without the level of care determination, the downstream financial and service analysis cannot proceed. The determination is also the gateway to specific protections: spousal impoverishment, the 300 percent SSI rule (a 2026 income cap of $2,982 per month for an individual), and the Olmstead integration mandate that requires consideration of community alternatives.

The practical stakes for families are real. A favorable determination opens nursing home Medicaid, which covers facility costs that would otherwise run into the tens of thousands of dollars each year, along with CCSP or SOURCE home-based services, ICWP coverage, Katie Beckett coverage for a child who could never qualify on parent income, or Money Follows the Person transition support. An unfavorable determination closes those doors.

Federal statutory and regulatory framework

Section 1919 of the Social Security Act

Section 1919 of the Social Security Act, enacted by the Omnibus Budget Reconciliation Act of 1987 (the Nursing Home Reform Act), is the federal foundation for nursing facility regulation. Section 1919(a) defines a "nursing facility" for Medicaid purposes. Section 1919(b) sets requirements covering residents' rights, quality of life, quality of care, resident assessment, comprehensive care plans, and nursing, rehabilitative, pharmacy, dietary, and social services. Section 1919(e)(7) establishes the PASRR framework, and Section 1919(f) addresses survey and certification.

42 CFR Part 483 implementing regulations

The implementing regulations sit at 42 CFR Part 483. Subpart B carries the core conditions of participation for long-term care facilities, Subpart C carries PASRR, Subpart D covers notice of rights and services, and Subpart F covers the distinct ICF/IID conditions of participation. The 2016 CMS reform (CMS-2424-F) substantially updated the long-term care conditions of participation; later rulemaking has addressed staffing, abuse prevention, and infection control.

The Minimum Data Set (MDS)

The Minimum Data Set 3.0 is the federal standardized resident assessment instrument required by 42 CFR 483.20. MDS 3.0 took effect October 1, 2010. It is completed on admission (the 5-day assessment), at 14 days, at 30 days, quarterly (within 92 days), annually (within 366 days), on a significant change in status, and for specific events such as discharge or return.

The MDS captures information across many domains. Section G records functional status and activities of daily living: bed mobility, transfer, walking, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. Section C records cognitive function using the Brief Interview for Mental Status (BIMS). Section D records mood using the PHQ-9 depression screen. Section E records behavioral symptoms. Section I records active diagnoses, and Section J records health conditions including pain, falls, and prognosis.

The MDS feeds care planning under 42 CFR 483.21, Nursing Home Compare quality measures and 5-star ratings, the Patient Driven Payment Model (PDPM) for Medicare skilled nursing facility reimbursement (effective October 1, 2019), and Medicaid case-mix adjusted per diem rates in states, including Georgia, that use MDS-based case mix. PDPM classifies residents into payment groups across six clinical categories (physical therapy, occupational therapy, speech-language pathology, nursing, non-therapy ancillaries, and a variable per diem adjustment), tying Medicare SNF payment to clinical complexity rather than therapy minutes.

PASRR: Preadmission Screening and Resident Review

PASRR rests on Section 1919(e)(7) and 42 CFR 483.100 through 483.138. It applies to every individual with mental illness or intellectual disability who applies to or resides in a Medicaid-certified nursing facility, regardless of who pays for the care. The purpose is to ensure that people with serious mental illness (SMI) or intellectual disability (ID) are not placed inappropriately in nursing facilities, and that when nursing facility placement is appropriate, they receive specialized services in addition to standard nursing facility services.

A Level I screen is completed before admission and identifies individuals with possible SMI, ID, or related conditions. When Level I flags a possible condition, a Level II evaluation is conducted by qualified mental health or developmental disability professionals not employed by the nursing facility. Level II determines whether the individual actually has SMI or ID, whether nursing facility placement is appropriate, and whether specialized services are needed beyond standard nursing facility care. The facility cannot decline admission solely because a resident needs specialized services; the state must arrange or provide them. PASRR allows categorical determinations under 42 CFR 483.130 for circumstances such as short convalescent stays, end-of-life situations, and certain dementia-as-primary diagnoses.

For the full Georgia screening workflow, contractor roles, and appeal paths, see our Georgia Medicaid PASRR guide.

How Georgia determines nursing facility level of care

DCH Office of Long-Term Care

The Georgia Department of Community Health (DCH), Division of Medicaid, Office of Long-Term Care administers Medicaid level of care determinations for institutional admissions and waiver eligibility. DCH publishes the State Plan provisions for nursing facility coverage and waiver applications, sets policy, and oversees the entities that conduct assessments.

DCH Healthcare Facility Regulation Division

Within DCH, the Healthcare Facility Regulation Division (HFRD) licenses and surveys nursing facilities for compliance with state licensure requirements and the federal conditions of participation at 42 CFR Part 483. Survey activities verify quality of care, resident rights, life safety, and infection control.

DBHDD PASRR Level II

The Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) administers PASRR Level II evaluations, the federally required second-stage review for individuals flagged with possible serious mental illness or intellectual disability. DBHDD regional offices coordinate evaluations through contracted clinicians, and the specialized services for SMI or ID identified through Level II are coordinated through DBHDD's ongoing service systems.

Area Agencies on Aging and the DON-R

The Area Agencies on Aging that cover Georgia's counties administer the Determination of Need-Revised (DON-R) for CCSP and SOURCE applicants. Care managers conduct in-home assessments using the standardized DON-R instrument, and the score determines whether the applicant meets NF LOC for CCSP or SOURCE eligibility. Families can reach the network through the Georgia Aging and Disability Resource Connection (ADRC).

ICWP and Katie Beckett assessments

ICWP uses a functional assessment tailored to severe physical disability and traumatic brain injury for adults who apply between the ages of 21 and 64, determining whether the applicant meets hospital or nursing facility level of care given physical functioning, medical complexity, and skilled care needs. DCH administers ICWP intake and assessment directly. The Katie Beckett TEFRA review uses physician-completed clinical documentation, a functional assessment, and a state-defined medical complexity threshold to determine whether the child would meet hospital or nursing facility level of care without home-based services; DCH manages the review through a contracted vendor.

The Determination of Need-Revised (DON-R)

The DON-R is Georgia's functional assessment tool for community-based long-term care under CCSP and SOURCE. It measures functional dependency across multiple domains and produces a numeric score that is compared against the NF LOC threshold.

The DON-R typically measures:

  • Activities of daily living (ADLs): bathing, dressing, eating, toileting, transferring, and mobility (indoor and outdoor)
  • Instrumental activities of daily living (IADLs): medication management, meal preparation, money management, telephone use, housekeeping, shopping, and transportation
  • Cognitive and behavioral function: memory, orientation, judgment, and behavior
  • Need for support: the frequency, intensity, and type of support needed

A qualified care manager from the Area Agency on Aging visits the applicant at home, observes, asks structured questions, and rates each domain. A composite score is computed and compared against the threshold for NF LOC. The thresholds and scoring methodology are set by DCH and applied uniformly across the Area Agencies. Applicants can request a copy of the assessment and the scoring documentation.

Georgia nursing home Medicaid eligibility: the financial side of level of care

Clinical NF LOC is only half of the test. To qualify for institutional or waiver Medicaid, an applicant must also meet Georgia's financial criteria, and the two determinations are made separately.

The 300 percent SSI special income rule

Section 1902(a)(10)(A)(ii)(VI) lets states extend Medicaid eligibility to individuals at incomes up to 300 percent of the federal SSI benefit rate for those at institutional level of care or in HCBS waiver alternatives. In 2026 the SSI federal benefit rate is $994 per month, so the 300 percent cap is $2,982 per month for an individual; Georgia also applies a $2,000 resource limit for an individual. This is the income pathway that complements clinical NF LOC, and it is how many seniors with Social Security or pension income above ordinary Medicaid limits still qualify. Applicants whose income exceeds the cap can still reach coverage through the medically needy spend-down pathway.

Spousal impoverishment

Section 1924, enacted in the Medicare Catastrophic Coverage Act of 1988, protects the community spouse when the other spouse needs long-term care. The spouse needing care must meet NF LOC. Under ACA Section 2404 and later extensions (most recently CAA 2023 §5121 through September 30, 2027), spousal impoverishment also extends to all 1915(c) HCBS waiver participants meeting NF LOC. In 2026 the community spouse keeps resources from a minimum of $32,532 up to a maximum of $162,660, and an income allowance (the Minimum Monthly Maintenance Needs Allowance) from $2,705.00 up to $4,066.50 per month.

Patient liability

Once eligible, an institutional resident contributes most of their income toward care. Medicaid pays the facility its rate minus the resident's "patient liability," which is the resident's income minus a personal needs allowance of $70 per month for a Georgia Medicaid member living in a nursing facility or institutionalized hospice, health insurance premiums (including Medicare premiums, deductibles, and coinsurance), certain medical expenses, and any community spouse income allowance. Georgia's $70 sits above the federal floor, which requires states to protect at least $30 a month for an aged, blind, or disabled resident.

Medicare SNF coverage versus Medicaid nursing facility coverage

A common source of confusion is the difference between Medicare skilled nursing facility (SNF) coverage and Medicaid nursing facility coverage. They are different programs with different criteria, time limits, and payment.

Medicare Part A covers up to 100 days of skilled nursing facility care per benefit period. It requires a prior 3-day inpatient hospital stay, a skilled care need, and admission to a Medicare-certified SNF within 30 days of discharge. Time spent under observation or in the emergency room before admission does not count toward the 3 days, and the 3-day minimum can be waived for beneficiaries in an ACO holding a SNF 3-Day Rule Waiver or in a Medicare Advantage plan that waives it, so check the plan before assuming the requirement applies. Days 1 through 20 carry no daily coinsurance; days 21 through 100 carry a daily coinsurance of $217 in 2026; after day 100 there is no Medicare SNF coverage in that benefit period. A benefit period ends once the beneficiary has been out of the hospital and SNF for 60 consecutive days.

Medicaid nursing facility coverage, by contrast, is ongoing custodial care that is not time-limited. It requires the NF LOC clinical determination, financial eligibility, and categorical eligibility (typically aged, blind, or disabled). Many families experience the Medicare-to-Medicaid hand-off during a single stay: Medicare covers the initial skilled rehabilitation, and when the benefit exhausts or the skilled need ends, the resident returns home, moves to another setting, or continues at the facility on Medicaid if eligible. Discharge planning under 42 CFR 483.21(c) is supposed to manage that transition.

For the admission workflow, facility selection, and the first 30 days of a nursing home stay, see our Georgia nursing facility admission process guide.

Olmstead and the integration mandate

The Supreme Court's decision in Olmstead v. L.C., 527 U.S. 581 (1999), held that unjustified institutionalization is discrimination under Title II of the Americans with Disabilities Act (ADA) at 42 USC 12132. States must provide community-based services when treatment professionals find community placement appropriate, the individual does not oppose it, and the placement can be reasonably accommodated given the state's resources. Level of care determinations operate against this integration mandate and cannot be used to channel people into institutions when community alternatives would work. Section 1915(c)(2)(C) requires freedom of choice between institutional and HCBS settings. Georgia's 2010 federal Olmstead settlement, focused on people with developmental disabilities and serious mental illness, drove substantial expansion of HCBS capacity, and Olmstead enforcement remains an ongoing federal interest.

Care planning, reassessment, and discharge

After admission and the initial MDS, the nursing facility must develop a comprehensive person-centered care plan within 7 days of completing the comprehensive MDS, under 42 CFR 483.21. An interdisciplinary team (physician, registered nurse, social services, dietitian, certified nursing assistant, and others as needed) builds the plan with the resident and family, sets measurable objectives and timetables, and reviews it quarterly and after any significant change. Under 42 CFR 483.10, the resident has the right to participate in planning and to access records, including the MDS.

MDS reassessments are required quarterly, annually, and on a significant change in status, meaning a major decline or improvement that affects multiple areas such as ADLs, cognition, mood, behavior, weight, skin, or medications. A significant change assessment triggers a care plan review. If a resident's condition has changed and a new MDS has not been completed, family advocacy or a complaint to the Long-Term Care Ombudsman is appropriate.

Discharge planning under 42 CFR 483.21(c) must begin at admission, not at the end of the stay. It addresses the resident's preferences, the services needed after discharge (HCBS waiver, home health, hospice, return to family, or alternative placement), equipment, caregiver training, follow-up appointments, and medications. Money Follows the Person transitions for residents who have been in an inpatient facility for at least 60 consecutive days, and who were receiving Medicaid for those inpatient services, are coordinated by transition coordinators who work with the resident, the family, the facility, and the waiver agency to develop a community plan and identify a waiver slot. Reserved capacity in the 1915(c) waivers helps ensure slot access for these transitions.

Appeals and fair hearings

An adverse level of care determination (a denial of NF LOC, a denial of waiver eligibility, or a reduction or termination of services) is an adverse benefit determination. Under Section 1902(a)(3) and 42 CFR 431.200 and following, the state must give written notice including the reason for the action, the regulation cited, the right to a hearing, the filing deadline, and the right to representation.

The request window. Under 42 CFR 431.221(d) the agency must allow a reasonable time, not to exceed 90 days from the date the notice of action is mailed, to request a hearing. That 90 days is a federal ceiling on the state's window, not a period you are guaranteed. Georgia's Medicaid policy directs that a hearing on an eligibility decision be requested within 30 days of the notice, a shorter window the federal rule permits. Read the deadline off your own notice rather than assuming either number, and note that a denial routed through a care management organization runs on its own timetable.

Keeping services during the appeal. The common shorthand that you have "10 days" is not quite the rule, and the difference decides whether coverage lapses. Under 42 CFR 431.230(a), if the agency sent the required advance notice and you request the hearing before the date of action stated on it, the agency may not reduce or terminate the service until a decision is rendered after the hearing, unless the only issue is one of federal or state law or policy. A request made after the action has already taken effect does not trigger that continuation; a separate provision, 42 CFR 431.231, lets the agency reinstate services when a hearing is requested not more than 10 days after the date of action, which is reinstatement rather than continuation. If your benefits continue and the agency's action is later sustained, 42 CFR 431.230(b) permits the agency to recoup the cost of the services furnished solely by reason of that continuation, not the cost of everything it paid during the appeal.

Hearings are held before an administrative law judge at the Office of State Administrative Hearings (OSAH).

Free legal help is available through the Georgia Legal Services Program and Disability Rights Georgia, and the Long-Term Care Ombudsman can assist with concerns about service quality or facility conduct. For the full appeal procedure, see our Georgia Medicaid appeals and fair hearings guide.

A note on the CMS minimum staffing rule

CMS finalized a minimum staffing rule for long-term care facilities in 2024, establishing 3.48 total nurse staffing hours per resident day, 0.55 registered nurse hours per resident day, 2.45 nurse aide hours per resident day, and 24/7 registered nurse coverage. The rule has been subject to legal challenge and the implementation timeline has shifted, so families and stakeholders should check current CMS guidance and DCH state survey activity for the enforcement status that applies now.

Worked examples

Eleanor, 78, Atlanta: dementia and nursing facility placement

After a fall and a hospitalization with cognitive decline, Eleanor's family considers nursing facility placement. The hospital social worker initiates PASRR Level I. Eleanor has moderate dementia and depression but no primary SMI diagnosis triggering Level II under Georgia's categorical decision for dementia-as-primary, so Level II is not required and admission proceeds. The 5-day MDS captures her cognitive function, ADL dependencies, mood, active diagnoses, and medications, and the interdisciplinary team builds a person-centered care plan within 7 days with her daughter Janet participating. Quarterly reassessments track her progression, and after 18 months a significant change assessment captures meaningful decline and the plan is revised. Eleanor's Medicaid eligibility was established under the 300 percent SSI rule because her Social Security income of $1,800 is below the $2,982 cap; her patient liability deducts the $70 personal needs allowance, leaving $1,730 per month toward facility costs.,

Marcus, 45, Macon: post-accident skilled rehab and Money Follows the Person

Marcus is admitted to a SNF for skilled rehabilitation after a spinal cord injury from a motor vehicle accident. Medicare Part A covers the first 20 days at no daily coinsurance, days 21 through 100 carry the $217 daily coinsurance, and PDPM sets his payment group from his rehab, nursing, and clinical complexity. PASRR Level I is completed at admission, and no Level II is triggered. After the Medicare benefit exhausts at day 100, Marcus continues at the SNF on Medicaid because he meets NF LOC clinically and qualifies financially under the 300 percent SSI rule. Once he has resided in the facility for 60 consecutive days and is receiving Medicaid for those inpatient services he can be considered for Money Follows the Person; days admitted for short-term rehabilitation now count toward that period, because the carve-out that once excluded them was repealed in 2021. A transition coordinator works with DCH and ICWP, an ICWP slot opens through reserved capacity, and Marcus moves home with personal support 8 hours daily, environmental modifications, case management, and medical equipment.

Aisha, 35, Savannah: serious mental illness and PASRR Level II

Aisha has chronic schizophrenia and arrives at the emergency department with an acute decompensation of diabetes that requires extended skilled care. Discharge planners initiate PASRR Level I, which flags possible SMI based on her diagnosis history. DBHDD coordinates Level II, and a contracted psychiatrist confirms the SMI, finds nursing facility placement appropriate for her current medical and functional needs, and identifies the need for specialized mental health services (medication management, behavioral health support, and social work coordination) in addition to standard nursing facility care. Aisha is admitted with those services documented in her care plan, and DBHDD continues to coordinate them. The Level II is revisited to assess whether placement remains appropriate or whether a community transition becomes feasible.

Jamil, 8, Albany: a medically complex child and Katie Beckett

Jamil has a complex congenital heart condition that requires ongoing pediatric cardiology care, durable medical equipment, and skilled nursing at home. His parents' combined income is well above regular Medicaid income limits, so without a special pathway he would not qualify. His pediatric cardiologist completes the Katie Beckett medical review, documenting that without home-based services Jamil would meet hospital or nursing facility level of care, with diagnostic documentation, a functional assessment, the medical interventions needed, the risk of acute decompensation, and family caregiver capacity. Georgia's contracted vendor approves eligibility under Section 1902(e)(3), parent income is disregarded, and Jamil receives the full state plan Medicaid benefit including private duty nursing 12 hours daily. His level of care is reviewed periodically; if his condition improves enough that he no longer meets the criteria, eligibility can end, with a right to appeal.

Diana, 72, Augusta: CCSP and SOURCE entry through the DON-R

Diana has Type 2 diabetes, COPD, and chronic kidney disease. After a hospitalization for diabetic complications, her geriatrician recommends home-based supports plus tight primary care coordination. Her family contacts the Georgia ADRC, which connects them to the Area Agency on Aging serving Richmond County. A care manager visits Diana at home and administers the DON-R, capturing her ADL dependencies (help with bathing and dressing), her IADL limitations (she cannot manage medications without supervision, cannot prepare meals safely, and needs transportation help), her cognitive status (mild impairment with intact judgment), and her need for support. Her composite score exceeds the NF LOC threshold under Georgia's CCSP and SOURCE criteria, and financial eligibility is confirmed: her Social Security income is below the $2,982 cap and her resources are below the $2,000 limit. Diana enrolls in SOURCE rather than CCSP given her medical complexity, so her primary care provider coordinates her diabetes, COPD, and CKD care alongside personal support, adult day health, and home-delivered meals.

Practical guidance for Georgia families

How to apply for a level of care determination

The pathway depends on the program:

  • Nursing facility Medicaid: apply through the Division of Family and Children Services (DFCS) for financial eligibility; the facility initiates PASRR Level I at admission, and the NF LOC determination is part of the eligibility review
  • CCSP or SOURCE: contact the Georgia ADRC at 1-866-552-4464 or the Area Agency on Aging serving your county
  • ICWP: contact ICWP case management at 770-961-6880
  • Katie Beckett TEFRA: contact the Katie Beckett office at 770-344-0823 and arrange physician documentation

What to expect, and your rights

For CCSP or SOURCE, a care manager visits the applicant at home and administers the DON-R; the visit usually takes 90 minutes to 2 hours and includes structured questions, observation, and a records review. For nursing facility care, PASRR Level I is completed at the hospital or by facility staff before admission, and the MDS is completed by the facility team within the required timelines. For Katie Beckett, the pediatrician or specialist completes the medical review form.

During any assessment you have the right to participate in the assessment and care planning under 42 CFR 483.10 and 42 CFR 441.301(c), to access your records including the MDS, to request a copy of the assessment and scoring methodology, to be accompanied by a family member or representative, to use a qualified interpreter, to a written decision with reasons, and to appeal.

What to do if a determination is denied

A denial is an adverse benefit determination that triggers appeal rights. Read the notice for the stated reasons, request the underlying documentation (assessment, scoring, and medical review), consider whether new clinical evidence supports reconsideration, and file the state fair hearing request by the deadline printed on the notice (Georgia's policy directs 30 days for an eligibility decision, within a federal ceiling of 90). If services are being reduced or terminated and you want them to keep running, file before the date of action shown on the notice and ask expressly for continuation. For help, contact the Georgia Legal Services Program at 1-833-457-7529 or Disability Rights Georgia at 1-800-537-2329, and bring concerns about facility actions to the Georgia Long-Term Care Ombudsman, the Division of Aging Services program that investigates complaints from residents of nursing homes, personal care homes, and assisted living.

Frequently Asked Questions

What is Georgia nursing facility level of care and why does it matter?

Nursing facility level of care (NF LOC) is a clinical and functional determination that an individual would require nursing facility care if community alternatives were unavailable. It is the gateway to nursing home Medicaid, the CCSP and SOURCE models inside Georgia's EDWP waiver, the ICWP waiver for adults with severe physical disabilities or traumatic brain injury, Katie Beckett TEFRA for medically complex children, and Money Follows the Person transitions. Without meeting NF LOC (or its functional equivalent for a specific pathway), the related long-term care Medicaid programs are not available, and every long-term care application in Georgia runs through some version of the determination.

What is the DON-R that Georgia uses for CCSP and SOURCE?

The Determination of Need-Revised (DON-R) is Georgia's functional assessment tool for applicants to CCSP and SOURCE, the two service-delivery models inside the EDWP waiver. It measures dependency in activities of daily living, instrumental activities of daily living, cognitive function, behavior, and need for support, and produces a composite score that is compared against the NF LOC threshold. A qualified care manager from the Area Agency on Aging administers it through an in-home visit, and you can request a copy of your score and the scoring methodology.

How does Georgia nursing home Medicaid eligibility work financially?

Clinical level of care is separate from the money test. For institutional and waiver Medicaid in 2026, Georgia's income cap is $2,982 per month for an individual (300 percent of the $994 SSI federal benefit rate) and the resource limit is $2,000 for an individual. Married applicants are protected by spousal impoverishment, which lets the community spouse keep resources from $32,532 up to $162,660 and a monthly income allowance from $2,705.00 up to $4,066.50 in 2026. If income exceeds the cap, the medically needy spend-down pathway may still open coverage.

How is Medicare SNF coverage different from Medicaid nursing facility coverage?

Medicare Part A covers up to 100 days of skilled nursing facility care per benefit period, with a prior 3-day inpatient hospital stay and a skilled need required (observation time does not count toward the 3 days, and an ACO with a SNF 3-Day Rule Waiver or a Medicare Advantage plan may waive the requirement); days 1 through 20 have no daily coinsurance, days 21 through 100 carry a $217 daily coinsurance in 2026, and coverage ends after day 100 in that benefit period. Medicaid nursing facility coverage is ongoing custodial care that is not time-limited, but it requires NF LOC, financial eligibility, and a patient liability calculation. Many families move from Medicare to Medicaid during a single stay.

Can I appeal a Georgia level of care denial, and how long do I have?

Yes. A denial of NF LOC or waiver eligibility is an adverse benefit determination under Section 1902(a)(3) and 42 CFR 431.200 and following. Federal law caps the request window at 90 days from the date the notice is mailed, and Georgia's Medicaid policy directs that a hearing on an eligibility decision be requested within 30 days, so use the deadline printed on your own notice. Keeping services running during the appeal turns on a different date: under 42 CFR 431.230(a) you must request the hearing before the date of action on the notice, and a request made afterward can at most lead the agency to reinstate services under 42 CFR 431.231 if it comes within 10 days of that date of action. Hearings are conducted by the Office of State Administrative Hearings (OSAH), and free legal help is available from the Georgia Legal Services Program at 1-833-457-7529 and Disability Rights Georgia at 1-800-537-2329.

Where to get help: Georgia level-of-care phone directory

If you or a loved one is navigating a Georgia long-term care application, assessment, or appeal, these are the contacts you may need.

DCH Office of Long-Term Care (LOC line) Institutional and waiver level-of-care policy. 404-657-7117
DCH PASRR Program Preadmission Screening and Resident Review coordination. 404-651-9961
Georgia Aging and Disability Resource Connection (ADRC) The statewide hotline routes by ZIP code to one of the 12 regional Area Agencies on Aging, the intake point for CCSP and SOURCE. 1-866-552-4464https://acl.gov/programs/veteran-directed-home-and-community-based-services/veteran-directed-home-community-based
DCH Healthcare Facility Regulation Division (HFRD) Nursing facility licensure, surveys, and complaints. 404-657-5550
DBHDD Intake and Evaluation PASRR Level II evaluations and NOW/COMP waivers. 1-800-715-4225
ICWP Case Management Independent Care Waiver Program intake and assessment. 770-961-6880
Katie Beckett TEFRA Medically complex children's eligibility and physician documentation. 770-344-0823
Georgia Long-Term Care Ombudsman Concerns about facility care, resident rights, and service quality. Run by the Division of Aging Services. aging.georgia.gov/programs-and-services/long-term-care-ombudsman-program
Disability Rights Georgia Free advocacy and legal help for people with disabilities. 1-800-537-2329
Medicare Medicare SNF benefits, coverage, and appeals. 1-800-MEDICARE
CMS Region IV (Atlanta) Federal Medicaid and nursing facility oversight for the Southeast. 404-562-7150

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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.

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