::hero{eyebrow="Georgia Medicaid" headline="Georgia Medicaid Nursing Facility Level of Care" subhead="How Section 1919 of the Social Security Act and 42 CFR Part 483 establish the federal nursing facility standard, how the Minimum Data Set 3.0 captures clinical functional and cognitive status, how PASRR Level I and Level II screen for serious mental illness and intellectual disability, how the Determination of Need-Revised tool operates the functional eligibility test for CCSP and SOURCE waivers, how the ICWP functional assessment works for adults with physical disabilities, how Katie Beckett TEFRA under Section 1902(e)(3) uses NF or hospital level of care to disregard parent income for medically complex children, how spousal impoverishment and the 300 percent SSI special income rule interact with the determination, how Olmstead integration shapes freedom of choice between institutional placement and HCBS, how DCH DPH and DBHDD administer the framework, and how Georgia families navigate the assessment care planning reassessment and transition process."} ::

Nursing facility level of care (NF LOC) is the gatekeeping clinical and functional determination that controls access to virtually every long-term services and supports pathway in Georgia Medicaid. For institutional Medicaid, it determines 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) home and community-based waivers, NF LOC is the threshold functional standard. For the Independent Care Waiver Program (ICWP), a functional equivalent of 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 and enhanced FMAP.

Every long-term care application in Georgia, whether for institutional placement or community-based services, runs through some version of the level of care determination. The instruments differ: the Minimum Data Set 3.0 for nursing facility residents, the Preadmission Screening and Resident Review for individuals with serious mental illness or intellectual disability, the Determination of Need-Revised for CCSP and SOURCE applicants, the ICWP functional assessment for physical disability, and the Katie Beckett medical and functional review for children. But 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.

For Georgia families navigating long-term care decisions, the level of care framework matters because it shapes everything 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 other eligibility factors. An unfavorable determination means the door is closed at the threshold, and the family must pursue alternative coverage (commercial insurance, Medicare, private pay, or appeal). Misunderstanding the framework leads families to pursue inappropriate care settings, miss out on services for which their loved one qualifies, or accept denials that should have been appealed.

This guide translates the level of care framework for Georgia families and stakeholders. It walks through the federal statutory and regulatory standards at Section 1919 and 42 CFR Part 483, the MDS 3.0 instrument and what it captures, the PASRR Level I and Level II screening process, Georgia's specific DON-R tool for CCSP and SOURCE, the ICWP functional assessment, Katie Beckett medical criteria, the interaction with financial eligibility (the 300 percent SSI special income rule and spousal impoverishment), the Olmstead integration mandate, care planning and reassessment requirements, discharge planning and Money Follows the Person, the distinction between Medicare SNF coverage and Medicaid nursing facility coverage, and the appeals framework. Worked examples illustrate how the framework plays out for real families. A frequently asked questions section addresses common questions. A contact directory provides the phone numbers families need.

::callout{title="Key takeaways"}

  • Section 1919 of the Social Security Act (enacted by OBRA 1987, the Nursing Home Reform Act) and 42 CFR Part 483 establish the federal nursing facility standard including resident rights, quality of care, comprehensive assessment, and PASRR.
  • The Minimum Data Set 3.0 (MDS), required by 42 CFR 483.20, is the federal standardized resident assessment instrument completed at admission (5-day), 14 days, 30 days, quarterly, annually, and on significant change. MDS feeds care planning, quality measures, Nursing Home Compare ratings, and Patient Driven Payment Model (PDPM) reimbursement effective October 1, 2019.
  • Preadmission Screening and Resident Review (PASRR) under Section 1919(e)(7) and 42 CFR 483.100 through 483.138 requires Level I screening before nursing facility admission and Level II evaluation when Level I identifies possible serious mental illness, intellectual disability, or related conditions.
  • Georgia's Determination of Need-Revised (DON-R) is the functional assessment tool for CCSP and SOURCE applicants. The DON-R measures dependency in activities of daily living, instrumental activities of daily living, cognitive function, behavior, and need for support across functional domains.
  • ICWP uses a functional assessment tailored to physical disability for adults ages 21 through 64.
  • Katie Beckett TEFRA under Section 1902(e)(3) uses hospital or nursing facility level of care medical and functional criteria to disregard parent income for eligibility of medically complex children.
  • The 300 percent SSI special income rule (Section 1902(a)(10)(A)(ii)(VI)) allows institutional and HCBS waiver Medicaid eligibility at incomes up to $2,982 monthly in 2026 (300 percent of the federal SSI benefit rate).
  • Spousal impoverishment under Section 1924, originally enacted in MCCA 1988, applies to nursing facility residents and (under ACA Section 2404 and subsequent extensions including CAA 2023 §5121) to all 1915(c) HCBS waiver participants meeting NF LOC. 2026 figures: CSRA $32,532 to $162,660; MMMNA $2,643.75 to $4,066.50.
  • Olmstead v. L.C., 527 U.S. 581 (1999), and ADA Title II at 42 USC 12132 establish that unjustified institutionalization is discrimination. NF LOC determinations must consider community alternatives. Section 1915(c)(2)(C) requires freedom of choice between institutional and HCBS settings.
  • DCH administers Medicaid LOC determinations. DPH Healthcare Facility Regulation Division surveys nursing facilities. DBHDD coordinates PASRR Level II for SMI and ID. Area Agencies on Aging administer CCSP/SOURCE DON-R.
  • 42 CFR 483.21 requires a comprehensive person-centered care plan within 7 days of the comprehensive MDS assessment, developed by an interdisciplinary team with resident and family participation.
  • Adverse LOC determinations are subject to state fair hearing under Section 1902(a)(3) and 42 CFR 431.200 et seq., with 30-day filing deadlines and aid-paid-pending rights if filed within 10 days. ::

Why level of care matters

By Brevy Care Team · Last verified May 12, 2026

Level of care is the clinical and functional finding that anchors long-term care eligibility. Every state Medicaid program operates some version of the determination because Section 1902(a)(13)(A) and the broader federal Medicaid framework require it. In Georgia, the determination operates across multiple pathways with overlapping but distinct instruments:

  • Institutional nursing facility Medicaid: NF LOC + financial eligibility under the 300 percent SSI rule + Section 1924 spousal impoverishment if married
  • CCSP and SOURCE waivers: NF LOC measured via DON-R + financial eligibility
  • ICWP waiver: physical disability ages 21-64 + functional equivalent of hospital or NF LOC
  • NOW and COMP waivers: developmental disability + ICF/IID level of care (not NF LOC, but analogous determination)
  • Katie Beckett TEFRA: hospital or NF LOC equivalent medical and functional criteria for the child
  • Money Follows the Person: NF LOC at time of institutional residence + 90+ days residence + community plan + waiver slot

Without the level of care determination, the entire downstream financial and service eligibility analysis cannot proceed. The determination is also the gateway to specific protections: spousal impoverishment, the 300 percent SSI rule, the Olmstead integration mandate that requires consideration of community alternatives.

For families, the practical impact is enormous. A favorable determination opens doors to nursing home Medicaid (which pays for facility costs of $90,000 to $120,000 annually), CCSP/SOURCE services (which can provide tens of thousands of dollars in annual home-based services), ICWP coverage (personal support, environmental modifications, equipment), Katie Beckett (full Medicaid coverage for a child whose family could never qualify based on parent income), or Money Follows the Person transition support. An unfavorable determination closes those doors.

Federal statutory and regulatory framework

Section 1919 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. The statute responded to widespread concerns about quality of care in nursing homes documented by the Institute of Medicine report Improving the Quality of Care in Nursing Homes (1986).

Section 1919(a) defines a "nursing facility" for Medicaid purposes: an institution primarily engaged in providing skilled nursing care, rehabilitation services, or health-related care and services that is not primarily a residential facility, and that meets the requirements of Section 1919(b), (c), and (d).

Section 1919(b) sets requirements for nursing facilities including:

  • Residents' rights
  • Quality of life
  • Quality of care
  • Resident assessment (Section 1919(b)(3))
  • Comprehensive care plans (Section 1919(b)(4)(C)(i))
  • Nursing services
  • Rehabilitative services
  • Pharmacy services
  • Dietary services
  • Activities
  • Social services
  • Specialized rehabilitative services
  • Environmental requirements

Section 1919(e)(7) establishes the PASRR framework, requiring states to operate preadmission screening for serious mental illness and intellectual disability.

Section 1919(f) addresses standards and survey activities.

42 CFR Part 483 implementing regulations

The implementing regulations are at 42 CFR Part 483:

  • Subpart B: Requirements for Long-Term Care Facilities (the core conditions of participation)
  • Subpart C: PASRR
  • Subpart D: Notice of Rights and Services
  • Subpart F: ICF/IID Conditions of Participation (a distinct framework for facilities serving people with intellectual disability)

The 2016 CMS reform (CMS-2424-F) significantly updated the long-term care conditions of participation. Subsequent rulemaking has addressed staffing, abuse prevention, infection control, and other quality issues.

Minimum Data Set 3.0

The Minimum Data Set is the federal standardized resident assessment instrument required by 42 CFR 483.20. MDS 3.0 took effect October 1, 2010, replacing earlier versions.

MDS is completed:

  • On admission (5-day assessment)
  • At 14 days
  • At 30 days
  • Quarterly (within 92 days)
  • Annually (within 366 days)
  • When status changes significantly (significant change in status assessment)
  • For specific events (discharge, return, swing-bed transitions)

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

MDS feeds:

  • Care planning under 42 CFR 483.21
  • Quality measures and Nursing Home Compare 5-star ratings
  • Patient Driven Payment Model (PDPM) for Medicare SNF reimbursement under Section 1888 (effective October 1, 2019, replacing the RUG classification)
  • Medicaid case-mix adjusted per diem in states (including Georgia) that use MDS-based case mix
  • Quality Indicators and Quality Measures for state and federal monitoring

PDPM classifies residents into payment groups based on six clinical categories: PT, OT, SLP, Nursing, Non-Therapy Ancillaries, and a Variable Per Diem adjustment. PDPM ties Medicare SNF payment to clinical complexity rather than therapy minutes (which was the focus under RUG-IV).

PASRR: Preadmission Screening and Resident Review

Section 1919(e)(7) and 42 CFR 483.100 through 483.138 establish the PASRR framework.

Purpose: PASRR ensures that individuals with serious mental illness (SMI) or intellectual disability (ID) are not placed inappropriately in nursing facilities, and when NF placement is appropriate, that they receive specialized services in addition to NF services.

Level I screening: a brief preadmission screen completed before admission to a Medicaid-certified nursing facility (with limited exemptions for short hospital-to-NF transitions and end-of-life situations). Level I identifies individuals with possible SMI, ID, or related conditions.

Level II evaluation: when Level I identifies possible SMI or ID, a Level II evaluation is conducted by qualified mental health or developmental disability professionals not employed by the nursing facility. Level II determines:

  1. Whether the individual actually has SMI/ID
  2. Whether NF placement is appropriate
  3. Whether specialized services for MI or ID are needed in addition to NF services

Specialized services: services specifically for the MI or ID condition, beyond standard NF services. The NF cannot decline admission solely because the resident needs specialized services; the state must arrange or provide them.

Categorical decisions: PASRR allows categorical determinations under 42 CFR 483.130. Common categorical exemptions include short-term convalescent stays following hospital discharge (typically up to 30 days) with appropriate physician certification, end-of-life situations, and dementia as primary diagnosis in specific circumstances.

State responsibility: Each state operates PASRR through designated authorities. In Georgia, DBHDD coordinates Level II evaluations through regional offices and contracted clinicians.

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 for institutional Medicaid. Under ACA Section 2404 and subsequent extensions (most recently CAA 2023 §5121 through September 30, 2027), spousal impoverishment also extends to all 1915(c) HCBS waiver participants meeting NF LOC.

2026 figures:

  • Community Spouse Resource Allowance (CSRA) minimum: $32,532
  • CSRA maximum: $162,660
  • Minimum Monthly Maintenance Needs Allowance (MMMNA): $2,643.75
  • Maximum MMMNA: $4,066.50

The community spouse retains income and resources up to these federal limits, protecting against impoverishment when the institutional or waiver spouse becomes Medicaid-eligible.

300 percent SSI special income rule

Section 1902(a)(10)(A)(ii)(VI) allows states to extend Medicaid eligibility to individuals at incomes up to 300 percent of the federal SSI benefit rate for individuals at institutional level of care or in HCBS waiver alternatives. The 2026 SSI federal benefit rate is $994 monthly; 300 percent is $2,982 monthly.

This is the income pathway that complements clinical NF LOC. A person can have income above regular Medicaid limits (which for most adults in Georgia are well below 300 percent SSI) and still qualify for institutional or waiver Medicaid if they meet NF LOC.

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 ADA at 42 USC 12132. States must provide community-based services when:

  1. Treatment professionals determine community placement is appropriate
  2. The individual does not oppose such placement
  3. Placement can be reasonably accommodated taking into account the state's resources

NF LOC determinations operate against this integration mandate. The determination cannot be used to channel people into institutional settings when community alternatives would be appropriate and accessible. Section 1915(c)(2)(C) explicitly requires freedom of choice between institutional and HCBS settings.

Georgia's 2010 DOJ Olmstead settlement focused on people with developmental disabilities and serious mental illness drove substantial expansion of HCBS capacity. Olmstead enforcement remains an ongoing federal interest.

Medicare SNF coverage versus Medicaid nursing facility coverage

A common source of family confusion is the distinction between Medicare skilled nursing facility coverage and Medicaid nursing facility coverage. They are different programs with different criteria, time limits, and payment structures.

Medicare Part A SNF benefit

Medicare Part A covers up to 100 days of skilled nursing facility care per spell of illness under Section 1862 and 42 CFR Part 409 Subpart C. To qualify:

  • Prior 3-day inpatient hospital stay (the "3-day rule" with some exceptions during PHE flexibilities)
  • Skilled care need (skilled nursing, physical therapy, occupational therapy, or speech therapy)
  • Admission to a Medicare-certified SNF within 30 days of hospital discharge

Coverage:

  • Days 1-20: full coverage, no daily coinsurance
  • Days 21-100: daily coinsurance ($217 daily in 2026, subject to annual adjustment)
  • After day 100: no Medicare SNF coverage in that spell of illness

Spell of illness ends when the beneficiary has been out of hospital and SNF for 60 consecutive days.

Medicaid nursing facility coverage

Medicaid nursing facility coverage is ongoing custodial care, not time-limited. To qualify:

  • NF LOC clinical determination
  • Financial eligibility (income within 300 percent SSI or medically needy spend-down; resources within $2,000 for an individual or with spousal impoverishment protections)
  • Categorical eligibility (typically aged, blind, or disabled)

Patient liability calculation: Medicaid pays the facility the rate minus the resident's "patient liability" or "applied income," which is the resident's income minus a personal needs allowance ($70 monthly in Georgia), health insurance premiums, certain medical expenses, and any community spouse income allowance under spousal impoverishment.

The hand-off

Many families experience the Medicare-to-Medicaid transition during a nursing facility stay. Medicare covers the initial skilled rehab period. When Medicare benefit exhausts (or skilled need ends), the resident either returns home, transitions to a different setting, or continues at the facility on Medicaid coverage if eligible. Discharge planning under 42 CFR 483.21(c) addresses this transition.

Georgia administration of level of care

DCH Office of Long-Term Care

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

DPH Healthcare Facility Regulation

The Georgia Department of Public Health, Healthcare Facility Regulation Division, surveys nursing facilities for compliance with state licensure requirements and federal conditions of participation under 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 administers PASRR Level II evaluations. DBHDD regional offices coordinate evaluations through contracted clinicians (psychiatrists, psychologists, DD professionals). Specialized services for MI or ID identified through Level II are coordinated through DBHDD ongoing service systems.

Area Agencies on Aging (DON-R)

The 12 Area Agencies on Aging covering Georgia's 159 counties administer the Determination of Need-Revised tool for CCSP and SOURCE applicants. Care managers conduct in-home assessments using the standardized DON-R instrument. The score determines whether the applicant meets NF LOC for CCSP/SOURCE eligibility.

ICWP functional assessment

ICWP uses a functional assessment tailored to physical disability for adults ages 21 through 64. Assessment determines whether the applicant meets hospital or nursing facility level of care given physical functioning, medical complexity, and need for skilled care. DCH directly administers ICWP intake and assessment.

Katie Beckett TEFRA medical review

Katie Beckett TEFRA review uses physician-completed clinical documentation, functional assessment, and a state-defined medical complexity threshold to determine whether the child would meet hospital or nursing facility LOC 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. The instrument measures functional dependency across multiple domains and produces a numeric score that compares against the NF LOC threshold.

DON-R typically measures:

Activities of Daily Living (ADLs):

  • Bathing
  • Dressing
  • Eating
  • Toileting
  • Transferring (bed to chair, etc.)
  • Mobility (indoor and outdoor)

Instrumental Activities of Daily Living (IADLs):

  • Medication management
  • Meal preparation
  • Money management
  • Telephone use
  • Housekeeping
  • Shopping
  • Transportation

Cognitive and behavioral function:

  • Memory
  • Orientation
  • Judgment
  • Behavior

Need for support:

  • Frequency of support needed
  • Intensity of support needed
  • Type of support needed

The DON-R is administered by qualified care managers from the Area Agency on Aging. The care manager 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.

DON-R thresholds and specific scoring methodology are established by DCH and applied uniformly across Area Agencies. Families and applicants can request a copy of the assessment and the scoring documentation.

PASRR in practice

PASRR Level I screening occurs before any individual is admitted to a Medicaid-certified nursing facility, with limited exemptions. The Level I is typically completed by the discharge planner at the referring hospital or the nursing facility intake staff using a standardized form.

If Level I identifies indicators of possible SMI, ID, or related conditions, Level II evaluation is triggered. DBHDD must complete the Level II within state-defined timeframes (typically 7-9 business days from Level I trigger).

The Level II evaluator (an independent qualified mental health or DD professional) reviews medical records, conducts an in-person evaluation, and documents:

  • Whether SMI or ID is confirmed
  • Whether NF placement is medically appropriate
  • Whether specialized services are needed in addition to NF services

The Level II recommendation flows to the nursing facility and to DBHDD for coordination of specialized services. The NF cannot decline admission solely on the basis of needing specialized services.

Categorical exemptions: PASRR allows categorical decisions for specific circumstances:

  • Convalescent care: short hospital-to-NF transitions for fewer than 30 days with appropriate physician certification of an acute medical episode
  • End-of-life care
  • Dementia as primary diagnosis with specific criteria (the Georgia categorical decision specifies when dementia exempts from Level II)

Care planning under 42 CFR 483.21

After admission and the initial MDS assessment, the nursing facility must develop a comprehensive person-centered care plan within 7 days of completing the comprehensive MDS. The care plan must:

  • Be developed by an interdisciplinary team including the resident's primary physician, registered nurse, social services professional, dietitian, certified nursing assistant, and other disciplines as needed
  • Include the resident's preferences and goals
  • Reflect cultural and linguistic considerations
  • Identify measurable objectives and timetables
  • Be reviewed quarterly and after significant change in status

The resident (and family or representative as appropriate) participates in care planning. 42 CFR 483.10 establishes resident rights including the right to participate in planning and to access records (including the MDS).

Reassessment requirements

MDS reassessments are required:

  • Quarterly (within 92 days of previous comprehensive assessment)
  • Annually (within 366 days)
  • On significant change in status (a major decline or improvement that affects multiple areas: ADLs, cognition, mood, behavior, weight, skin, medications)
  • For specific events (discharge, return, swing-bed transitions)

Significant change assessments trigger care plan review and modification. Families and residents should track changes in function and ensure assessments capture them. If a resident's condition has changed significantly and a new MDS has not been completed, family advocacy or a complaint to the Long-Term Care Ombudsman may be appropriate.

Discharge planning

42 CFR 483.21(c) requires discharge planning to begin at admission, not at the end of the stay. The discharge plan must address:

  • Resident preferences for transition
  • Services needed in the post-discharge setting (HCBS waiver, home health, hospice, return to family, alternative placement)
  • Equipment and supplies
  • Caregiver training
  • Follow-up appointments
  • Medications
  • Connection with community-based services as appropriate

Money Follows the Person (MFP) transitions for residents who have been in a nursing facility for 90+ days are coordinated through transition coordinators. The transition coordinator works with the resident, family, the nursing facility, and the waiver administering agency (DAS, DBHDD, or DCH) to develop a community plan and identify a waiver slot. Reserved capacity in 1915(c) waivers ensures slot access for MFP transitions.

Appeals and fair hearings

Adverse LOC determinations (denial of NF LOC, denial of waiver eligibility, reduction or termination of services) are adverse benefit determinations subject to:

  • Notice: Section 1902(a)(3) and 42 CFR 431.200 et seq. require written notice including reason for action, citation of regulation, right to hearing, deadline to request, and right to representation
  • Filing deadline: 30 days for state fair hearing request
  • Aid paid pending: if request is filed within 10 days of notice, services continue during appeal
  • Hearing: before an administrative law judge at the Office of State Administrative Hearings (OSAH)
  • Decision: within 90 days of request
  • Federal review: limited federal review through CMS if state hearing process is exhausted

Free legal assistance is available through Georgia Legal Services Program and Disability Rights Georgia. The Long-Term Care Ombudsman can assist with concerns about service quality or facility conduct.

CMS minimum staffing rule and ongoing reform

CMS finalized a minimum staffing rule for long-term care facilities in 2024 establishing:

  • 3.48 total nurse staffing hours per resident day (HPRD)
  • 0.55 RN HPRD
  • 2.45 nurse aide HPRD
  • 24/7 RN coverage

The rule has been subject to legal challenge. Implementation timelines have varied. Families and stakeholders should consult current CMS guidance and DPH state survey activities for current enforcement status.

Worked examples

Eleanor 78 Atlanta dementia and NF placement

Eleanor lives in DeKalb County. After a fall and hospitalization with cognitive decline, her family considers nursing facility placement. The hospital social worker initiates PASRR Level I. Eleanor has moderate dementia and depression but not a primary SMI diagnosis triggering Level II under Georgia's categorical decision for dementia-as-primary. Level II is not required; admission can proceed.

Eleanor is admitted to a nursing facility. The 5-day MDS captures her cognitive function (BIMS score), ADL dependencies (Section G), mood (PHQ-9 in Section D), active diagnoses (Section I), health conditions (Section J), and medications (Section N).

The interdisciplinary team develops a person-centered care plan within 7 days. Eleanor's daughter Janet participates in the planning conference. The plan identifies goals around dementia care, fall prevention, depression management, and quality of life. Quarterly MDS reassessments track Eleanor's progression. After 18 months, a significant change MDS captures meaningful decline; the care plan is revised to reflect more intensive dementia care and end-of-life planning conversations.

Eleanor's Medicaid eligibility was established under the 300 percent SSI rule (her Social Security income of $1,800 is below the $2,982 threshold). Her patient liability calculation deducts a $70 monthly personal needs allowance, leaving $1,730 monthly toward facility costs. Medicaid pays the difference between the facility rate and the patient liability.

Marcus 45 Macon post-MVA skilled rehab and MFP

Marcus is admitted to a SNF for skilled rehabilitation after acute hospitalization for spinal cord injury sustained in a motor vehicle accident. Medicare Part A covers the first 20 days at no daily coinsurance. PDPM classifies his payment group based on his rehab needs, nursing needs, and clinical complexity. MDS at 5-day, 14-day, and 30-day intervals captures his progress.

PASRR Level I is completed at admission; no Level II is triggered (Marcus has neither SMI nor ID).

After Medicare benefit exhausts at day 100, Marcus continues at the SNF on Medicaid coverage. He meets NF LOC clinically (functional dependency from spinal cord injury). His Medicaid eligibility is established under the 300 percent SSI rule.

After 90 days of institutional residence, Marcus qualifies for Money Follows the Person. A transition coordinator works with Marcus, the SNF, and DCH ICWP to develop a community transition plan. An ICWP slot becomes available through reserved capacity. Marcus transitions home with personal support 8 hours daily, environmental modifications (ramp, accessible bathroom), case management, and specialized medical equipment.

Aisha 35 Savannah SMI PASRR Level II

Aisha has chronic schizophrenia and presents to the ED with medical needs (acute decompensation of diabetes with significant functional limitation) requiring extended skilled care. Discharge planners initiate PASRR Level I; the screen identifies possible SMI based on her diagnosis history.

DBHDD coordinates PASRR Level II. A contracted psychiatrist conducts the evaluation, reviews medical records, and confirms:

  1. Aisha has SMI (chronic schizophrenia)
  2. NF placement is appropriate for her medical and functional needs at this time
  3. Specialized mental health services are needed in addition to standard NF services (medication management, behavioral health support, social work coordination)

Aisha is admitted with the specialized services documented in her care plan. DBHDD continues coordination of specialized mental health services through the NF's social services department and external providers. The Level II is reviewed at intervals to assess whether NF placement remains appropriate or whether community transition is feasible.

Jamil 8 Albany medically complex Katie Beckett

Jamil has a complex congenital heart condition requiring ongoing pediatric cardiology care, durable medical equipment, and skilled nursing in the home. His parents earn $95,000 combined, which is above regular Medicaid income limits.

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. The review includes:

  • Diagnostic documentation
  • Functional assessment
  • Medical interventions needed (medications, equipment, skilled nursing)
  • Risk of acute decompensation without home-based services
  • Family caregiver capacity

Georgia's Katie Beckett review (through the contracted vendor) approves eligibility under Section 1902(e)(3). Parent income is disregarded. Jamil receives the full state plan Medicaid benefit including private duty nursing 12 hours daily.

Jamil's level of care is reviewed periodically. As long as the medical and functional criteria continue to be met, eligibility continues. If Jamil's condition improves significantly, the review could find he no longer meets the criteria, ending Katie Beckett eligibility (with right to appeal).

Diana 72 Augusta CCSP entry and DON-R

Diana has Type 2 diabetes, COPD, and chronic kidney disease. After hospitalization for diabetic complications, her geriatrician recommends home-based supports plus tight primary care coordination.

Diana's family contacts the Georgia Aging and Disability Resource Center, which connects them to the Area Agency on Aging serving Richmond County. A care manager visits Diana at home and administers the Determination of Need-Revised.

The DON-R captures her ADL dependencies (assistance needed for bathing and dressing), her IADL limitations (cannot manage medications without supervision; cannot prepare meals safely; needs transportation assistance), cognitive status (mild cognitive impairment, intact judgment), and need for support across functional domains.

Diana's composite score exceeds the NF LOC threshold under Georgia's CCSP/SOURCE criteria. Financial eligibility is also confirmed (income from Social Security is below the 300 percent SSI threshold; resources are below the $2,000 individual limit).

Diana enrolls in SOURCE rather than CCSP given her medical complexity. SOURCE's primary care medical home model means her primary care provider coordinates all her care including diabetes management, COPD treatment, CKD monitoring, and HCBS services. SOURCE services include personal support 4 hours daily, adult day health 3 days weekly, and home-delivered meals.

Tyrell 24 Columbus IDD PASRR Level II for short-term skilled rehab

Tyrell has Down syndrome and is admitted to a nursing facility for short-term skilled rehabilitation after orthopedic surgery. The hospital discharge planner initiates PASRR Level I; the screen identifies ID.

DBHDD coordinates PASRR Level II. A contracted developmental disability professional conducts the evaluation and determines:

  1. Tyrell has ID (Down syndrome with cognitive impairment)
  2. NF placement is appropriate for the limited duration of skilled rehab (categorical decision for short-term convalescent care applies but specialized services are still indicated)
  3. Specialized developmental disability services are needed during the stay (familiar communication supports, behavioral consultation, family education)

The NF coordinates with DBHDD for specialized service delivery during the stay. Upon discharge planning, the NF and DBHDD connect Tyrell with his existing NOW waiver provider (he has been on NOW since age 22). Tyrell discharges home with his ongoing community living supports and a follow-up plan for orthopedic recovery.

Practical guidance

How to apply for a level of care determination

The pathway depends on which program you are applying to:

  • Nursing facility Medicaid: apply through DFCS (Division of Family and Children Services) for financial eligibility; the NF will initiate PASRR Level I at admission; NF LOC determination is part of the financial eligibility review
  • CCSP or SOURCE: contact the Georgia Aging and Disability Resource Center 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 in the assessment

For CCSP/SOURCE: a care manager from the Area Agency on Aging visits the applicant at home and administers the DON-R. The assessment typically takes 90 minutes to 2 hours and includes structured questions, observation, and review of medical records.

For nursing facility: PASRR Level I is completed at the hospital or by NF staff before admission. MDS assessments are completed by the NF interdisciplinary team within timelines (5-day, 14-day, etc.).

For Katie Beckett TEFRA: the pediatrician or specialist completes a Katie Beckett-specific medical review form. Additional functional documentation may be requested.

What your rights are during the assessment

  • Right to participate in the assessment and care planning under 42 CFR 483.10 and 42 CFR 441.301(c)
  • Right to access your records including the MDS and other assessment instruments
  • Right to request a copy of the assessment and scoring methodology
  • Right to be accompanied by a family member or representative
  • Right to use a qualified interpreter if needed
  • Right to a written decision with reasons
  • Right to appeal

What to do if a level of care determination is denied

A denial is an adverse benefit determination triggering appeal rights:

  1. Read the notice carefully to understand the reasons for denial
  2. Request the underlying documentation (assessment, scoring, medical review)
  3. Consider whether new clinical evidence supports a reconsideration request
  4. File a state fair hearing request within 30 days
  5. Request aid paid pending if filing within 10 days (continuation of services)
  6. Contact Georgia Legal Services (1-833-457-7529) or Disability Rights Georgia (1-800-537-2329) for assistance
  7. Engage the Long-Term Care Ombudsman (1-866-552-4464) for concerns about nursing facility actions

How to track changes in status

Families and residents should track changes in function over time. Significant changes (a major decline or improvement in ADLs, cognition, mood, behavior, weight, or skin) trigger MDS reassessment and care plan review under 42 CFR 483.20. If a significant change has occurred and the assessment has not been completed, family advocacy or a complaint to the Long-Term Care Ombudsman is appropriate.

How Brevy can help

Brevy's care navigators help Georgia families understand the level of care framework, prepare for assessments, navigate PASRR, advocate during MDS care planning, transition from institutional to community settings via Money Follows the Person, appeal denials, and connect with legal and ombudsman support. Our team includes social workers, registered nurses, and benefits specialists with deep experience in Georgia long-term care. Visit brevy.com to learn more about our services or to request a no-cost consultation.

::accordion :::accordion-item{title="What is 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. NF LOC is the gateway to nursing home Medicaid, the CCSP and SOURCE HCBS waivers, the ICWP waiver for adults with physical disabilities, Katie Beckett TEFRA for medically complex children, and Money Follows the Person transitions. Without meeting NF LOC (or its functional equivalent for specific pathways), the related long-term care Medicaid programs are not available. Every long-term care application in Georgia runs through some version of the determination. :::

:::accordion-item{title="What is the Minimum Data Set (MDS) and what does it do?"} The Minimum Data Set 3.0 is the federal standardized resident assessment instrument required by 42 CFR 483.20 for every nursing facility resident. MDS is completed at admission (5-day), 14 days, 30 days, quarterly, annually, and on significant change. It captures functional status (ADLs), cognitive function (BIMS), mood (PHQ-9), behavior, active diagnoses, health conditions, medications, and many other domains. MDS feeds care planning under 42 CFR 483.21, Nursing Home Compare quality measures, and Patient Driven Payment Model (PDPM) reimbursement effective October 1, 2019. :::

:::accordion-item{title="What is PASRR and when does it apply?"} Preadmission Screening and Resident Review (PASRR) under Section 1919(e)(7) and 42 CFR 483.100 through 483.138 requires Level I screening before nursing facility admission. If Level I identifies possible serious mental illness, intellectual disability, or related conditions, a Level II evaluation is conducted by qualified mental health or DD professionals. Level II determines whether the diagnosis is confirmed, whether NF placement is appropriate, and whether specialized services are needed. Georgia DBHDD coordinates Level II. Exemptions exist for short convalescent stays, end-of-life care, and dementia-as-primary diagnosis under specific criteria. :::

:::accordion-item{title="What is the Determination of Need-Revised (DON-R)?"} The DON-R is Georgia's functional assessment tool for CCSP and SOURCE waiver applicants. The DON-R measures dependency in activities of daily living, instrumental activities of daily living, cognitive function, behavior, and need for support across functional domains. A composite score above the threshold establishes NF LOC for CCSP/SOURCE eligibility. The DON-R is administered by qualified care managers from the Area Agency on Aging through an in-home assessment. :::

:::accordion-item{title="How does the 300 percent SSI special income rule work?"} 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 monthly; 300 percent is $2,982 monthly. This income pathway complements clinical NF LOC and is essential for many seniors with Social Security or pension income above regular Medicaid limits. :::

:::accordion-item{title="How does spousal impoverishment apply to NF LOC?"} Section 1924, enacted in MCCA 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 subsequent extensions including CAA 2023 §5121 through September 30, 2027, spousal impoverishment applies to all 1915(c) HCBS waiver participants meeting NF LOC as well as nursing facility residents. 2026 figures: CSRA $32,532 to $162,660; MMMNA $2,643.75 to $4,066.50. :::

:::accordion-item{title="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 spell of illness, with prior 3-day hospital stay and skilled need required. Days 1-20 have no daily coinsurance; days 21-100 require coinsurance ($217 daily in 2026); after day 100 Medicare SNF coverage ends in that spell. Medicaid nursing facility coverage is ongoing custodial care, not time-limited, but requires NF LOC, financial eligibility, and patient liability calculation. Many families experience the Medicare-to-Medicaid transition during a nursing facility stay. :::

:::accordion-item{title="What is Katie Beckett TEFRA and how does NF LOC apply?"} Katie Beckett TEFRA is authorized by Section 1902(e)(3) (added by TEFRA 1982 Section 134). It uses hospital or nursing facility level of care equivalent medical and functional criteria to disregard parent income for the child's Medicaid eligibility. Katie Beckett is technically a state plan eligibility category, not a 1915(c) waiver, but functions as Georgia's primary HCBS pathway for medically complex children. Pediatric specialist documentation establishes the medical criteria; functional assessment establishes the functional criteria. :::

:::accordion-item{title="What does the Olmstead decision mean for level of care?"} Olmstead v. L.C., 527 U.S. 581 (1999), held that unjustified institutionalization is discrimination under ADA Title II at 42 USC 12132. States must provide community-based services when treatment professionals find community placement appropriate, the individual does not oppose it, and placement can be reasonably accommodated. NF LOC determinations must consider community alternatives. Section 1915(c)(2)(C) requires freedom of choice between institutional and HCBS settings. Georgia's 2010 DOJ Olmstead settlement focused on people with developmental disabilities and serious mental illness has driven HCBS expansion for over a decade. :::

:::accordion-item{title="How long does a level of care determination take in Georgia?"} Timelines depend on the pathway. PASRR Level I is completed before nursing facility admission. PASRR Level II (when triggered) must be completed within state-defined timeframes (typically 7-9 business days). CCSP/SOURCE DON-R is part of the broader application process (often 30-45 days). ICWP functional assessment occurs at intake. Katie Beckett TEFRA review timelines vary based on medical documentation completeness. Section 1902(a)(8) reasonable promptness applies; excessive delays can support advocacy and complaint. :::

:::accordion-item{title="Can I appeal a level of care denial?"} Yes. A denial of NF LOC, waiver eligibility, or related determinations is an adverse benefit determination triggering appeal rights under Section 1902(a)(3) and 42 CFR 431.200 et seq. Filing deadline is 30 days for state fair hearing request. If filed within 10 days, services continue during appeal (aid paid pending). Hearings are conducted by the Office of State Administrative Hearings (OSAH). Free legal assistance is available from Georgia Legal Services (1-833-457-7529) and Disability Rights Georgia (1-800-537-2329). :::

:::accordion-item{title="What is Money Follows the Person and how does it interact with NF LOC?"} Money Follows the Person (MFP), authorized by DRA 2005 and extended through CAA 2023, supports transitions from nursing facilities, ICF/IIDs, and other institutional settings to community-based care. To qualify, the resident must have been in the institution for 90+ days, meet NF LOC at the time of institutional residence, want to transition, and have a feasible community plan. MFP provides enhanced FMAP for 12 months post-transition, transition coordination, and reserved capacity in 1915(c) waivers to ensure slot access. :::

:::accordion-item{title="How often is MDS reassessed and what does it mean for care planning?"} MDS reassessments occur quarterly, annually, and on significant change in status (a major decline or improvement affecting multiple areas: ADLs, cognition, mood, behavior, weight, skin, medications). Significant change reassessments trigger comprehensive care plan review and modification. Families and residents should track changes in function and ensure assessments capture them. If a significant change has occurred and a new MDS has not been completed, advocacy or complaint to the Long-Term Care Ombudsman (1-866-552-4464) may be appropriate. :::

:::accordion-item{title="Who can help me navigate a level of care determination in Georgia?"} For CCSP, SOURCE, or general aging and disability questions, call the Aging and Disability Resource Center at 1-866-552-4464. For ICWP, call 770-961-6880. For Katie Beckett TEFRA, call 770-344-0823. For PASRR concerns, contact DBHDD Intake at 1-800-715-4225. For appeals or legal assistance, call Georgia Legal Services at 1-833-457-7529 or Disability Rights Georgia at 1-800-537-2329. The Long-Term Care Ombudsman at 1-866-552-4464 can assist with concerns about nursing facility actions. ::: ::

::cta{title="Georgia Medicaid Level of Care: Phone Directory" body="If you or a loved one is navigating a Georgia long-term care application, assessment, or appeal, these are the contacts you may need. Save them. Use them. Advocate."}

  • DCH Medicaid Member Services: 1-866-211-0950
  • DCH Office of Long-Term Care: 404-657-7117
  • DCH PASRR Program: 404-651-9961
  • Georgia Aging and Disability Resource Center: 1-866-552-4464 (CCSP, SOURCE, MFP, Long-Term Care Ombudsman)
  • DPH Healthcare Facility Regulation Division: 404-657-5550
  • DBHDD Intake and Evaluation: 1-800-715-4225 (PASRR Level II, NOW/COMP)
  • ICWP Case Management: 770-961-6880
  • Katie Beckett TEFRA: 770-344-0823
  • Georgia Long-Term Care Ombudsman: 1-866-552-4464
  • Disability Rights Georgia: 1-800-537-2329
  • Georgia Legal Services Program: 1-833-457-7529
  • Georgia Healthcare Association: 770-735-3300
  • LeadingAge Georgia: 404-872-9191
  • Medicare: 1-800-MEDICARE
  • CMS Region IV (Atlanta): 404-562-7150
  • Brevy Care Navigation: brevy.com ::

Find personalized help navigating Georgia nursing facility level of care at brevy.com.

This guide reflects federal law and Georgia Medicaid policy as of May 12, 2026. Federal regulations, state plan amendments, CMS guidance, assessment instruments, and determination procedures change periodically. Always verify current rules, assessment criteria, timelines, and procedures with DCH, the relevant administering agency, or your care manager, support coordinator, or attorney. Brevy publishes informational guides at brevy.com to help Georgia families navigate eldercare, disability services, and Medicaid. Brevy is not a law firm and does not provide legal advice. For legal questions about level of care, denials, appeals, or rights, consult Georgia Legal Services Program (1-833-457-7529) or Disability Rights Georgia (1-800-537-2329).

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Brevy Care Team

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