Nursing Facility Services are provided by Medicaid certified nursing homes, which primarily provide three types of services:
- Skilled nursing or medical care and related services;
- Rehabilitation needed due to injury, disability, or illness;
- Long term care —health-related care and services (above the level of room and board) not available in the community, needed regularly due to a mental or physical condition.
A Nursing Facility is one of many settings for long term care, including or other services and supports outside of an institution, provided by Medicaid or other state agencies.
Where Nursing Facility Services are provided
Medicaid coverage of Nursing Facility Services is available only for services provided in a nursing home licensed and certified by the state survey agency as a Medicaid Nursing Facility (NF). See NF survey and certification requirements. Medicaid Nursing Facility Services are available only when other payment options are unavailable and the individual is eligible for the Medicaid program.
In many cases it is not necessary to transfer to another nursing home when payment source changes to Medicaid NF. Many nursing homes are also certified as a Medicare skilled nursing facility (SNF), and most accept long term care insurance and private payment. For example, commonly an individual will enter a Medicare Skilled Nursing Facility (SNF) following a hospitalization that qualifies him or her for a limited period of SNF services. If nursing home services are still required after the period of SNF coverage, the individual may pay privately, and use any long term care insurance they may have. If the individual exhausts assets and is eligible for Medicaid, and the nursing home is also a Medicaid certified nursing facility, the individual may continue to reside in the nursing home under the Medicaid NF benefit. If the nursing home is not Medicaid certified, he or she would have to transfer to a NF in order to be covered by the Medicaid Nursing Facility benefit.
Who may receive Nursing Facility Services
Nursing facility services for are required to be provided by state Medicaid programs for individuals age 21 or older who need them. States may not limit access to the service, or make it subject to waiting lists, as they may for HCBS. Therefore in some cases NF services may be more immediately available than other long term care options. NF residents and their families should investigate other long-term care options in order to transition back to the community as quickly as possible.
Need for nursing facility services is defined by states, all of whom have established NF level of care criteria. State level of care requirements must provide access to individuals who meet the coverage criteria defined in Federal law and regulation. Individuals with serious mental illness or intellectual disability must also be evaluated by the state's PASRR program to determine if NF admission is needed and appropriate.
Nursing Facility Services for individuals under age 21 is a separate Medicaid service, optional for states to provide. However all states provide the service, and in practice there is no distinction between the services.
In some states individuals applying for NF residence may be eligible for Medicaid under higher eligibility limits used for residents of an institution. See your state Medicaid agency for more information.
Services included in the NF Benefit
A NF participating in Medicaid must provide, or arrange for, nursing or related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident.
There is no exhaustive list of services a NF must provide, in that unique resident needs may require particular care or services in order to reach the highest practicable level of well being. The services needed to attain this level of well-being are established in the individual's plan of care.
Specific to each state, the general or usual responsibilities of the NF are shaped by the definition of NF service in the state's Medicaid State plan, which may also specify certain types of limitations to each service. States may also devise levels of service or payment methodologies by acuity or specialization of the nursing facilities.
Federal requirements specify that each NF must provide, (and residents may not be charged for), at least:
- Nursing and related services
- Specialized rehabilitative services (treatment and services required by residents with mental illness or intellectual disability, not provided or arranged for by the state)
- Medically-related social services
- Pharmaceutical services (with assurance of accurate acquiring, receiving, dispensing, and administering of drugs and biologicals)
- Dietary services individualized to the needs of each resident
- Professionally directed program of activities to meet the interests and needs for well being of each resident
- Emergency dental services (and routine dental services to the extent covered under the state plan)
- Room and bed maintenance services
- Routine personal hygiene items and services
Residents may be charged for:
- Private room, unless medically needed
- Specially prepared food, beyond that generally prepared by the facility
- Telephone, television, radio
- Personal comfort items including tobacco products and confections
- Cosmetic and grooming items and services in excess of those included in the basic service
- Personal clothing
- Personal reading materials
- Gifts purchased on behalf of a resident
- Flowers and plants
- Social events and activities beyond the activity program
- Special care services not included in the facility's Medicaid payment
This summary is for general information. Specific requirements for Medicaid nursing facilities may be found primarily in law at section 1919 of the Social Security Act, in regulation primarily at 42 CFR 483 subpart B, and in formal CMS guidance documents. Also see: