Tip for State-specific LOC form

The level of care assessment determines eligibility for ALL Medicaid long-term care services — not just nursing facility placement

Tip for State-specific LOC form

Many states use the same assessment to determine eligibility for home and community-based waiver programs

Tip for State-specific LOC form

Functional decline should be well-documented in medical records before the assessment

MedicaidhardDoctor signature required

Level of Care (LOC) Assessment

State-specific LOC form · State Medicaid Agencies

Clinical assessment determining whether an individual meets the institutional level of care required for HCBS waiver enrollment. Criteria vary by state.

Form Details

Total fields: 80
Auto-fillable: 50 (63%)
Time without BeneFill: 60 minutes
Time with BeneFill: 15 minutes
Time saved: 45 minutes
Filled by: doctor
Frequency: annual
State-specific: Yes — form may vary by state

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Where to Submit This Form

📠

Submit to the state Medicaid agency or its designated assessment entity

Required for Medicaid-funded long-term care services. Each state has its own assessment tool and process.

🏢

Assessment conducted in person by the state's assessment team at the individual's current location

Filing Deadline

Must be completed before Medicaid-funded long-term care services begin. Reassessments required annually or with significant changes in condition.

Required Attachments

📎 Completed level of care assessment form (state-specific)
📎 Medical records and physician documentation
📎 Functional assessment (ADLs, IADLs, cognitive function)
📎 Current diagnoses, medications, and treatment plans
📎 Social and environmental assessment

Processing Time

Initial assessment: 2-4 weeks for scheduling and completion. State determination: 1-2 weeks after the assessment. Total: 3-6 weeks from referral to determination.

What Happens Next

The state determines whether the individual meets the level of care required for the requested service (nursing facility, HCBS waiver, etc.). If approved, Medicaid-funded services can begin. If denied, the individual has the right to appeal through a fair hearing.

Tips for This Form

✓ The level of care assessment determines eligibility for ALL Medicaid long-term care services — not just nursing facility placement
✓ Many states use the same assessment to determine eligibility for home and community-based waiver programs
✓ Functional decline should be well-documented in medical records before the assessment
✓ If the assessment does not reflect the individual's true functional status, request a reassessment and provide additional documentation

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Temporary Medicaid coverage granted by qualified entities (hospitals, clinics) based on preliminary income assessment. Covers services until full application is processed.

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Annual renewal verifying continued Medicaid eligibility. Includes income, expenses, and household composition. Failure to complete results in disenrollment.

Medicaid Spend-Down Documentation

State-specific · State Medicaid Agencies

Documents medical expenses applied toward meeting the spend-down amount. Once the difference between income and the medically needy income level is met, Medicaid covers remaining expenses.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Medicaid Agencies or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.