Nursing Home Level of Care by State: How Medicaid Decides (2026)

Federal Medicaid rules don't require any particular assessment tool, so each state uses its own instrument, assessor and cut-off to decide who needs a nursing home level of care.1 Federal law sets the frame, including the care levels being tested and a hearing right when coverage is denied or cut.2,3,4 If your parent is about to be assessed, the state-by-state table shows their state's instrument, who decides, the threshold and how often it is rechecked.

In This Guide

• How Nursing Home Level of Care Is Determined Everywhere
• Nursing Home Level of Care Criteria by State
• If Your Parent Already Lives in a Nursing Home
• How PACE Rechecks Level of Care
• Why Daily-Activity Counts Aren't the Whole Test
• If the Answer Is No
• Getting Ready for the Assessment
• Level of Care Is Only Half of Eligibility
• Frequently Asked Questions
• Learn More

How Nursing Home Level of Care Is Determined Everywhere

These are the federal rules every state works inside. Our glossary entry on nursing facility level of care defines the term.

What federal law defines

Section 1919(a) of the federal Medicaid statute defines a nursing facility as one primarily providing skilled nursing care, rehabilitation, or regular health-related care to people whose condition requires care "above the level of room and board" that is available only through institutional facilities.8

What a waiver evaluation tests

For a Section 1915(c) home and community-based services waiver, the state must evaluate whether the person needs the level of care of a hospital, a nursing facility, or an intermediate care facility for individuals with intellectual disabilities, and whether, without waiver services, the person would otherwise be institutionalized. The state must reevaluate each Section 1915(c) waiver participant at least once a year.2

The intermediate care facility level turns on "active treatment," so intellectual disability waivers sit behind a different gate than the one in the table below.9

Where each state writes down its own process

Under 42 CFR 441.303(c), a state must tell CMS who makes level-of-care evaluations and how, supply the evaluation form, and describe how it ensures regular reevaluations. In the CMS waiver application this is Appendix B-6, "Evaluation/Reevaluation of Level of Care," which asks for the evaluating entity, the assessors' qualifications, the criteria, the instrument, and a reevaluation schedule no less often than annually.10

What federal law does not fix

The Medicaid and CHIP Payment and Access Commission (MACPAC) reported in a June 2016 report chapter that the federal government does not require states to use a particular assessment tool to determine eligibility. MACPAC's 2015 inventory found 124 distinct functional assessment tools in use across the 50 states and DC, and states used three different tools each on average.1

Nursing Home Level of Care Criteria by State

Each row states only what a verified source says (October 2026). "Not verified" means no verified source we hold states that item; it does not mean the state has none. Where a row names one program, the entry applies to that program only.

Georgia: the waiting-list score is not the level-of-care test

For Georgia's Elderly and Disabled Waiver, the Determination of Need-Revised (DON-R) score from the first screening sets the applicant's place on the waiting list. The level of care itself is determined at a later in-home assessment, and services start after a physician certifies the need for nursing home care.23

Mississippi: two documents disagree

Mississippi's administrative code, in the Division of Medicaid's compilation effective August 1, 2026, sets a PASRR Level I score of 50 or more. The Division's August 2022 eLTSS training materials describe a replacement LTSS Screening Tool scored 0 to 3, and they noted that code updates were pending.39 Ask the Division which version it applies to your case.

If Your Parent Already Lives in a Nursing Home

PASRR screening

Preadmission Screening and Resident Review (PASRR) applies to nearly everyone who applies to or lives in a Medicaid-certified nursing facility, whatever the payer, though some hospital discharges and readmissions skip the preadmission screen. A Level I screen identifies people suspected of having a serious mental illness or intellectual disability. When Level I is positive, a Level II evaluation decides whether the person needs the nursing facility level of care and whether they need specialized services.73 Our guide to PASRR resident review and discharge covers what happens when a review finds a resident no longer needs a nursing home.

The MDS assessment schedule

Under 42 CFR 483.20, a certified nursing home must assess each resident with the CMS resident assessment instrument, which includes the Minimum Data Set (MDS). A certified nursing home's comprehensive resident assessment is due within 14 calendar days after admission, within 14 calendar days after a significant change in condition, and at least once every 12 months, with a quarterly review at least once every 3 months.74

Medicare is a different test

Medicare Part A covers skilled nursing facility care only on a short-term, post-acute basis, up to 100 days per benefit period and generally after a qualifying inpatient hospital stay of at least three days. Medicare Part A does not pay for long-term custodial care.75

How PACE Rechecks Level of Care

To enroll in the Program of All-Inclusive Care for the Elderly (PACE), a person must be 55 or older, live in the PACE organization's service area, and be determined by the state to need the nursing facility level of care set by the state Medicaid plan.76

Under 42 CFR 460.160(b), the state must reevaluate a PACE participant's nursing facility level of care at least once a year. For PACE, the state may permanently waive the annual recertification when there is no reasonable expectation of improvement or significant change because of the severity of a chronic condition or the degree of functional impairment.77

Losing level of care on paper does not automatically end PACE. If the state finds a PACE participant no longer meets the nursing facility level of care, the participant may be deemed to remain eligible until the next annual reevaluation if, without continued PACE coverage, they would reasonably be expected to meet the requirement again within the next 6 months.77

Why Daily-Activity Counts Aren't the Whole Test

Counting activities of daily living (ADLs) is only part of the test in some states.

Virginia

Under 12VAC30-60-303, functional capacity alone is not sufficient to show a need for nursing facility admission or for Medicaid home and community-based services. The screening criteria have three parts: functional capacity, medical or nursing needs, and the risk of nursing facility admission within 30 days of the screening date. DMAS's screening manual tells screeners that a person must meet all three to meet nursing facility level of care.65

Kentucky

Under 907 KAR 1:022, a person does not meet low-intensity nursing care status if their needs are limited to verbal or gestural help with ADLs, independent use of a wheelchair, walker, crutch or cane, a minor restrictive diet, or medications needing only minimal help such as set-up or simple cuing.6

Where state rules do count ADLs, the counts differ: help with any ADL in South Dakota, 2 or more listed ADLs in New Hampshire, and 3 or more in New Jersey's Managed Long Term Services and Supports (MLTSS) standard.59,44,45

If the Answer Is No

Under 42 CFR 431.201, an "action" includes a termination, suspension or reduction of Medicaid eligibility or of covered services. The agency generally must send notice at least 10 days before the date of action, stating the reasons and the right to a hearing. If a hearing is requested before the date of action, services generally continue until the hearing decision, and the agency may recover the cost of those services if its action is upheld.4

Under 42 CFR 431.220, the state must offer a hearing to anyone whose claim for eligibility or services is denied, and to anyone who believes the state made an erroneous PASRR determination.3 Federal rules allow up to 90 days from the date the notice is mailed to ask for a hearing, and a state may set a shorter window, so use the deadline on your notice.7 See Medicaid appeals and fair hearings and keeping coverage during an appeal. If a managed care plan says a resident no longer needs nursing home care, see what to do when a Medicaid plan stops paying for the nursing home.

Not meeting the nursing home level doesn't always rule out home care. Under Section 1915(i), a state may cover home and community-based services without an institutional level-of-care finding, as long as its institutional criteria are stricter than its 1915(i) criteria, and a 1915(i) finding that a person is not eligible is a hearable action.78 Section 1915(c)(11), a new option for states, lets HHS approve waivers for people who don't meet an institutional level of care, with approvals beginning July 1, 2028.79

Getting Ready for the Assessment

State instructions can shape how an assessment is scored. Wisconsin's functional-screen instructions, for example, tell screeners to describe a person whose abilities vary day to day as they are on a "bad" day.80 Ask your state's agency for its assessment instructions before the visit.

Level of Care Is Only Half of Eligibility

Meeting nursing home level of care does not settle whether Medicaid pays. North Carolina, for one, states that nursing facility prior approval does not guarantee financial eligibility or Medicaid payment.48 The financial gate (income, assets, spousal protections) is covered in nursing home Medicaid by state. The home-care programs this gate opens are in Medicaid HCBS waivers by state, and income too high for a Medicaid waiver covers what to do when income is the problem.

Learn More

Find personalized help working out your state's level-of-care assessment 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.