Michigan Medicaid Nursing Facility Level of Care Determination

Medicaid beneficiaries and Medicare/Medicaid dual beneficiaries seeking Medicaid reimbursed long-term care services from a Medicaid-certified nursing facility, the Program of All Inclusive Care for the Elderly (PACE), the MI Choice Program, or MI Health Link must meet the Medicaid State Agency’s definition of Nursing Facility (NF) Level of Care (LOC).  The criteria that determine NF LOC is outlined in the Michigan Medicaid Nursing Facility Level of Care Determination (LOCD). 

The LOCD must be conducted in CHAMPS via MILogin according to Medicaid policy located in the Medicaid Provider Manual.  

The LOC Determination is to be completed by the nursing facility, MI Choice, or PACE provider prior to the beneficiary's admission or enrollment.  Medicaid services will not be reimbursed unless the beneficiary is determined medically/functionally eligible through the web-based LOC Determination.  The web-based LOC Determination must be completed within 14 calendar days from the date of a new admission of a Medicaid beneficiary.

Policy requirements and other related provider-specific information for:

  • Nursing Facilities, can be found in the Medicaid Provider Manual, Nursing Facility Coverages Chapter, Beneficiary Eligibility and Admission Process.
  • PACE can be found in the  Medicaid Provider Manual, PACE Chapter, Eligibility and Enrollment
  • MI Choice can be found in the Medicaid Provider Manual, MI Choice Chapter, Eligibility, Enrollment, Services and Administration, etc.

Supplemental information is also available through the following links:

 Nursing Facility Level of Care Determination Contact Information 

 

LOC Determination Provider Helpline 

 1-800-292-2550 

 providersupport@michigan.gov 

Billing questions, LOC Determination process. 
Michigan Peer Review Organization (MPRO)   1-800-727-7223

(select Long-Term Care Exception Criteria option) 

Provider Request for an Exception Review or Beneficiary Request for an Immediate Review Process for ineligible applicants. 
Nursing Facility Transition Team    517-241-4293  Assistance transitioning ineligible beneficiaries to alternative settings after all other options and appeal rights have been exhausted. 

 

LOC Determination Form  

Providers may utilize a hard copy of the LOC Determination to gather information.  However, the online LOC Determination must be completed as indicated in the policy* in order for reimbursement to be made.

LOC Determination of Field Definitions    

The LOC Field Definitions provides definitions for each question/answer field in the LOC Determination. 

Freedom of Choice Form 

Michigan's Informed Choice Process is part of the LOC Determination.  The Informed Choice Process ensures that applicants are informed of all nursing facility level of care program options under Medicaid.  It also informs applicants of their right to request an exception to the criteria and provides information on the appeals process.   

Nursing Facility Level of Care Exception Process 

Michigan's Nursing Facility Level of Care Exception Process is available for applicants who do not meet the LOC Determination criteria, but who demonstrate a significant need for long-term care.  To request an exception, contact MPRO.

Long Term Care Adverse Action Notices 

Refer to the provider-specific policy links above for more information regarding beneficiary notice requirements.  For an immediate review of adverse action notices, beneficiaries may contact MPRO.

  • Adequate Notice
    An Adequate Notice must be sent when the new applicant appears to be ineligible for services based on the Michigan Medicaid Nursing Facility Level of Care Determination. It also applies to MI Choice new applicants who request a Level of Care Determination, but the program is currently at capacity.
    Nursing Facility        MI Choice Program  
  • Advance Action Notice 
    An Advance Action Notice must be sent when the current applicant is receiving program services, but is no longer functionally eligible for services based on the Nursing Facility Level of Care Determination process and attempts at discharge planning have failed.  The Nursing Facility Transition Team is available to assist.
    Nursing Facility        MI Choice Program  
  • Request for an Administrative Hearing Form (DCH-0092)
    The provider must supply a copy of the DCH-0092 to the applicant when the applicant believes a decision is inappropriate.   DCH-0092    Michigan Administrative Hearing System website
     

Michigan Medicaid Nursing Facility Level of Care Determination Process Guidelines 

The Process Guidelines explain the process requirements for admission to Michigan's three primary long-term care programs:  Medicaid-reimbursed nursing facility care, Home and Community-Based Services for the Elderly and Disabled (MI Choice Program) and the Program of All-Inclusive Care for the Elderly (PACE). 

Access Guidelines to State Services for Persons with Long Term Care Needs 

The Access Guidelines assist providers of long term care services to determine appropriate referrals for applicants seeking long term care services.  The guidelines are presented for provider information. 

Telephone Intake Guidelines 

A list of questions that may be used to identify potential in-person assessments are provided in the Telephone Intake Guidelines. These guidelines are optional and available for use by nursing facilities, hospitals, and the Program of All-Inclusive Care for the Elderly (PACE).

The Telephone Intake Guidelines do not determine program eligibility.   PDF Format    WORD Format